Provider Demographics
NPI:1902437718
Name:WALDEN, CONNIE E
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:E
Last Name:WALDEN
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 1:251 E FORHAN ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-2242
Mailing Address - Country:US
Mailing Address - Phone:678-541-1382
Mailing Address - Fax:
Practice Address - Street 1:251 E FORHAN ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-2242
Practice Address - Country:US
Practice Address - Phone:678-541-1382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider