Provider Demographics
NPI:1699499384
Name:THOMAS, CONNIE MARIE (DNP)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DNP
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 205
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-0205
Mailing Address - Country:US
Mailing Address - Phone:618-554-8730
Mailing Address - Fax:
Practice Address - Street 1:3002 JOHN DUFFY DR
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1656
Practice Address - Country:US
Practice Address - Phone:248-660-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023000802363L00000X, 363LP0808X, 363LG0600X, 363LP0808X
AR218965363L00000X, 363LP0808X, 363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR294786758Medicaid
MO420119243Medicaid