Basic Information
| Provider Information | |||||||||
| NPI: | 1326409152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNELLY | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | KRISTIN | ||||||||
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| Credential: | RN, MSN, CPNP-AC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 WILSHIRE BLVD STE 600 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900102814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233613550 | ||||||||
| FaxNumber: | 3233618052 | ||||||||
| Practice Location | |||||||||
| Address1: | 4650 W SUNSET BLVD | ||||||||
| Address2: | MAIL STOP 66 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900276062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233614148 | ||||||||
| FaxNumber: | 3233613668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2016 | ||||||||
| LastUpdateDate: | 12/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0222X | 95003749 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics, Critical Care | 363LP0200X | 95003749 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 2080P0214X | 95003749 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
No ID Information.