Provider Demographics
NPI:1073537205
Name:CONNOLLY, MARY ELLEN (NP)
Entity Type:Individual
Prefix:MS
First Name:MARY ELLEN
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64226
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4742
Mailing Address - Country:US
Mailing Address - Phone:410-328-6897
Mailing Address - Fax:410-328-2109
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-6897
Practice Address - Fax:410-328-2109
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR085542363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD64470401OtherBLUE SHIELD
MD0101OtherCAREFIRST REGIONAL
MD64470401OtherBLUE SHIELD
MD0101OtherCAREFIRST REGIONAL