Provider Demographics
NPI:1306354261
Name:JOHNSON-WILTZ, CONNIE DENISE (FNP-BC)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:DENISE
Last Name:JOHNSON-WILTZ
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2933 PARK PLAZA LN
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642-5516
Mailing Address - Country:US
Mailing Address - Phone:409-983-1899
Mailing Address - Fax:409-300-4310
Practice Address - Street 1:2933 PARK PLAZA LN
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-5516
Practice Address - Country:US
Practice Address - Phone:409-983-1899
Practice Address - Fax:409-300-4310
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-12
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX703409363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily