Provider Demographics
NPI:1548858202
Name:LASLEY, CONNIE JEANINE (CRNP)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:JEANINE
Last Name:LASLEY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:J
Other - Last Name:SALTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:300 MEDICAL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420-1108
Mailing Address - Country:US
Mailing Address - Phone:334-222-2393
Mailing Address - Fax:
Practice Address - Street 1:300 MEDICAL AVE STE 100
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420-1108
Practice Address - Country:US
Practice Address - Phone:334-222-2393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-082667363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner