Basic Information
| Provider Information | |||||||||
| NPI: | 1609527068 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONNELLY | ||||||||
| FirstName: | BRITTANY | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5318 NE 114TH ST | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986864529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609895408 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1718 E KESSLER BLVD | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986321842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607475800 | ||||||||
| FaxNumber: | 3605753846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2022 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA-2202 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA61308534 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.