Provider Demographics
NPI:1154870558
Name:SEACRIST, CONNIE C
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:C
Last Name:SEACRIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CELIA
Other - Middle Name:
Other - Last Name:GARZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:79398 MONTEGO CT
Mailing Address - Street 2:20
Mailing Address - City:BERMUDA DUNES
Mailing Address - State:CA
Mailing Address - Zip Code:92203-8015
Mailing Address - Country:US
Mailing Address - Phone:760-989-5476
Mailing Address - Fax:
Practice Address - Street 1:47915 OASIS ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6950
Practice Address - Country:US
Practice Address - Phone:760-989-5476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA534311163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health