Provider Demographics
NPI:1396777603
Name:HARGRAVE, CONNIE M (CRNA)
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:M
Last Name:HARGRAVE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 52662
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-2662
Mailing Address - Country:US
Mailing Address - Phone:337-893-5466
Mailing Address - Fax:
Practice Address - Street 1:118 N HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ABBEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70510-4039
Practice Address - Country:US
Practice Address - Phone:337-893-5466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA02568367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1395463Medicaid
LA59512Medicare PIN