Basic Information
| Provider Information | |||||||||
| NPI: | 1578738712 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OEN | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 329 N WEST ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458014332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192213072 | ||||||||
| FaxNumber: | 4195495671 | ||||||||
| Practice Location | |||||||||
| Address1: | 1550 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458012823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195160327 | ||||||||
| FaxNumber: | 4192258878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 04/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | CNP.10025 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0005073 | 01 | OH | OHIO PARAMEDIC | OTHER | 2290846 | 05 | OH | MEDICAID |