NPIMap

Individual provider Active NPI

Connie L. Davis

  • Nephrology Physician
  • Mount Vernon, WA
National Provider Identifier
1043395841
Registry record updated Mar 13, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nephrology PhysicianTaxonomy code 207RN0300X
License
MD00025078 Issued in WA
Practice address
208 Hospital Parkway
Mount Vernon, WA 98274
Phone
(360) 428-8260
Fax
(360) 428-8576
NPI assigned
Oct 27, 2006
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 13, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Nephrology Physician 207RN0300X MD00025078 WA Primary

Addresses

Primary practice location

208 Hospital Parkway
Mount Vernon, WA 98274

Mailing address

1400 E. Kincaid Street
Attn: Credentialing
Mount Vernon, WA 98274-4127
Phone (360) 428-2500

Other identifiers 2

IdentifierTypeStateIssuer
9149OtherINTERNAL ID-MOTOR VEHICLE ID
8303687MedicaidWA

Other names 1

  • Connie L. Dyberg Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
MD00025078WAMDNephrology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Northwest Kidney Centers PastSince Jan 15, 2023 Accepting new patients
Northwest Kidney Centers Past Accepting new patients
Public Hospital Dist No 1 Skagit Past Accepting new patients
Public Hospital Dist No 1 Skagit Past Accepting new patients

Interoperability endpoints

  • Direct secure messaging: cdavis13314@skagit.direct-ci.com

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1161907200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1426204800000",
    "number": "1043395841",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1400 E. KINCAID STREET",
            "address_2": "ATTN: CREDENTIALING",
            "city": "MOUNT VERNON",
            "state": "WA",
            "postal_code": "982744127",
            "telephone_number": "360-428-2500",
            "fax_number": "360-428-6485"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "208 HOSPITAL PARKWAY",
            "city": "MOUNT VERNON",
            "state": "WA",
            "postal_code": "98274",
            "telephone_number": "360-428-8260",
            "fax_number": "360-428-8576"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DAVIS",
        "first_name": "CONNIE",
        "middle_name": "L.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-10-27",
        "last_updated": "2015-03-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207RN0300X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Nephrology",
            "state": "WA",
            "license": "MD00025078",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "INTERNAL ID-MOTOR VEHICLE ID",
            "identifier": "9149",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8303687",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "CONNIE",
            "last_name": "DYBERG",
            "middle_name": "L.",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Mount Vernon, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 13, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.