Basic Information
| Provider Information | |||||||||
| NPI: | 1528090297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNELLY | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | R.N., A.C.N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 251 WESTPARK WAY STE 210 | ||||||||
| Address2: | |||||||||
| City: | EULESS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760403742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6822363656 | ||||||||
| FaxNumber: | 8558139308 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 WESTPARK WAY STE 210 | ||||||||
| Address2: | |||||||||
| City: | EULESS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760403742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6822363656 | ||||||||
| FaxNumber: | 8558139308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 09/02/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 456277 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 088288803 | 05 | TX | MEDICAID | 088288805 | 05 | TN | MEDICAID | 088288804 | 05 | TX | MEDICAID | 088288806 | 05 | TX | MEDICAID |