Basic Information
Provider Information | |||||||||
NPI: | 1164990131 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CONNERS | ||||||||
FirstName: | ARIEL | ||||||||
MiddleName: | GRACE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 19117 MARBLE GLEN LN | ||||||||
Address2: |   | ||||||||
City: | PFLUGERVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 786603593 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1725 W HARRISON ST STE 710 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606123863 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3129423034 | ||||||||
FaxNumber: | 3125632519 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2018 | ||||||||
LastUpdateDate: | 12/04/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/04/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | AP138356 | TX | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 041-470175 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.