Provider Demographics
NPI:1114624970
Name:CONNOLLY, STACY NICOLE
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:NICOLE
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:NY
Mailing Address - Zip Code:10996-1109
Mailing Address - Country:US
Mailing Address - Phone:845-938-0628
Mailing Address - Fax:845-938-0627
Practice Address - Street 1:900 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:NY
Practice Address - Zip Code:10996-1109
Practice Address - Country:US
Practice Address - Phone:845-938-0628
Practice Address - Fax:845-938-0627
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3069207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine