Basic Information
Provider Information | |||||||||
NPI: | 1609280254 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HODGES - MCCORMICK | ||||||||
FirstName: | CONNIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NURSE PRACTITIONER | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HODGES | ||||||||
OtherFirstName: | CONNIE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NURSE | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3011 N MICHIGAN ST | ||||||||
Address2: |   | ||||||||
City: | PITTSBURG | ||||||||
State: | KS | ||||||||
PostalCode: | 667622546 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202319873 | ||||||||
FaxNumber: | 6202315062 | ||||||||
Practice Location | |||||||||
Address1: | 3011 N MICHIGAN ST | ||||||||
Address2: |   | ||||||||
City: | PITTSBURG | ||||||||
State: | KS | ||||||||
PostalCode: | 667622546 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202319873 | ||||||||
FaxNumber: | 6202315062 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2014 | ||||||||
LastUpdateDate: | 12/07/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TP0016X | 53-75726-061 | KS | N |   | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) | 363LP0808X | 75726 | KS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.