Provider Demographics
NPI:1104221308
Name:CONNELL, ETRENDA (RN)
Entity Type:Individual
Prefix:
First Name:ETRENDA
Middle Name:
Last Name:CONNELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2807 ARROWLEAF DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-2771
Mailing Address - Country:US
Mailing Address - Phone:229-245-6565
Mailing Address - Fax:229-245-6561
Practice Address - Street 1:206 S PATTERSON ST
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-5668
Practice Address - Country:US
Practice Address - Phone:229-245-6565
Practice Address - Fax:229-245-6561
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN057301163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse