Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | MD00033643 | WA |
NPI | 1043540651 |
---|---|
Provider Name | Dr. Connie Lou Landrum |
First Address | Port Angeles, WA 98362 |
Second Address | Port Angeles, WA 98363 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2010 |
Last Update Date | 04/01/2010 |