Provider Demographics
NPI:1447880448
Name:HARVEY, CONNIE MARIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIE
Last Name:HARVEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11832 NEWCASTLE AVE STE 11-12
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-8997
Mailing Address - Country:US
Mailing Address - Phone:225-291-1164
Mailing Address - Fax:225-291-1165
Practice Address - Street 1:11832 NEWCASTLE AVE STE 11-12
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8997
Practice Address - Country:US
Practice Address - Phone:225-291-1164
Practice Address - Fax:225-291-1165
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-19
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15156251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1012149Medicaid
LA1012106Medicaid
LA1012092Medicaid