Provider Demographics
NPI:1093363285
Name:CONNOLLY, LEEANN (RD)
Entity Type:Individual
Prefix:
First Name:LEEANN
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02356-1336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:99 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-1336
Practice Address - Country:US
Practice Address - Phone:508-297-1245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA126133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered