Provider Demographics
NPI:1043280340
Name:CONNELLY, RICHARD F (RNC, FNP)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:F
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:RNC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4261 BIG CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:TN
Mailing Address - Zip Code:37753-2220
Mailing Address - Country:US
Mailing Address - Phone:423-487-2249
Mailing Address - Fax:423-487-3707
Practice Address - Street 1:4261 BIG CREEK RD
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:TN
Practice Address - Zip Code:37753-2220
Practice Address - Country:US
Practice Address - Phone:423-487-2249
Practice Address - Fax:423-487-3707
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN90651163W00000X
TNAPN6635363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN100011036OtherPHP TENNCARE
TN3073336OtherBLUECARE-C.HILL
TN3348042Medicaid
TN3348042Medicaid