Provider Demographics
NPI:1104493865
Name:AHN, CONNIE (NP)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:AHN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 NE MOTHER JOSEPH PL STE 330
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-3288
Mailing Address - Country:US
Mailing Address - Phone:360-514-2990
Mailing Address - Fax:
Practice Address - Street 1:406 SE 131ST AVE STE 104
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4031
Practice Address - Country:US
Practice Address - Phone:877-522-1275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202105283NP-PP363LF0000X
WAAP61185290363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily