Provider Demographics
NPI:1063184968
Name:REZZONICO, CONNOR (PMHNP)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:REZZONICO
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 W PARK PL STE 222
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2784
Mailing Address - Country:US
Mailing Address - Phone:208-625-7695
Mailing Address - Fax:949-864-3597
Practice Address - Street 1:1110 W PARK PL STE 222
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2784
Practice Address - Country:US
Practice Address - Phone:208-625-7695
Practice Address - Fax:949-864-3567
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP70005328363LP0808X
ID74368363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health