Basic Information
| Provider Information | |||||||||
| NPI: | 1356526115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNOLLY | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | LOU | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.N. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | CONNIE | ||||||||
| OtherMiddleName: | LOU | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | R.N. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 162 GROVE ST STE J | ||||||||
| Address2: | |||||||||
| City: | BISHOP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935142652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608736533 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 162 GROVE ST STE J | ||||||||
| Address2: | |||||||||
| City: | BISHOP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935142652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608736533 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2007 | ||||||||
| LastUpdateDate: | 06/21/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP2201X | 68232 | CO | N | Nursing Service Providers | Registered Nurse | Ambulatory Care | 163WC0400X | 815310 | CA | Y | Nursing Service Providers | Registered Nurse | Case Management |
No ID Information.