Basic Information
| Provider Information | |||||||||
| NPI: | 1861618381 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCONNELL | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BS | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 300 13TH AVE W | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DICKINSON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586014879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012277585 | ||||||||
| FaxNumber: | 7012277575 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 13TH AVE W | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | DICKINSON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586014879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012277585 | ||||||||
| FaxNumber: | 7012277575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 12/31/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 54523 | 05 | ND | MEDICAID |