Basic Information
| Provider Information | |||||||||
| NPI: | 1790751642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALE | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 PICCADILLY CIR | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711117127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184224620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3018 OLD MINDEN RD STE 1117 | ||||||||
| Address2: | |||||||||
| City: | BOSSIER CITY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711122497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187461935 | ||||||||
| FaxNumber: | 3187462514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 09/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0802X | AP03832 | LA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 276400000X | AP03832 | LA | N | Hospital Units | Rehabilitation, Substance Use Disorder Unit | 283Q00000X | AP03832 | LA | N | Hospitals | Psychiatric Hospital | 363LF0000X | AP03832 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | AP03832 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1189537 | 05 | LA | MEDICAID |