Basic Information
| Provider Information | |||||||||
| NPI: | 1669980280 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNOR | ||||||||
| FirstName: | CORIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | A-GNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6983 HILLSDALE CT | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178498350 | ||||||||
| FaxNumber: | 3175766311 | ||||||||
| Practice Location | |||||||||
| Address1: | 8051 S EMERSON AVE STE 350 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462378634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178591020 | ||||||||
| FaxNumber: | 3178594040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2018 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 28162979A | IN | N | Nursing Service Providers | Registered Nurse | 363LG0600X | 71008080A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 300018116 | 05 | IN | MEDICAID |