Basic Information
| Provider Information | |||||||||
| NPI: | 1730455395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCONNELL | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1200 MOUNTAIN ST | ||||||||
| Address2: | STE 230 | ||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897033823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758852229 | ||||||||
| FaxNumber: | 7758825045 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 MOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7752835075 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2012 | ||||||||
| LastUpdateDate: | 03/24/2017 | ||||||||
| 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 | 2080P0204X | DR.0055733 | CO | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 208000000X | 16408 | NV | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.