Provider Demographics
NPI:1447672357
Name:JOHANNA CONGLETON, CNM, PA
Entity type:Organization
Organization Name:JOHANNA CONGLETON, CNM, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALATHI
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-406-9911
Mailing Address - Street 1:6750 N MACARTHUR BLVD
Mailing Address - Street 2:100
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-2875
Mailing Address - Country:US
Mailing Address - Phone:972-406-9911
Mailing Address - Fax:
Practice Address - Street 1:9 MEDICAL PKWY PLAZA 4
Practice Address - Street 2:STE 103
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7858
Practice Address - Country:US
Practice Address - Phone:972-406-9911
Practice Address - Fax:972-406-9930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-11
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXCNM1795367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX345079301Medicaid
TX744687OtherNURSE LICENSE #
TX15228OtherRX AUTH #