Provider Demographics
NPI:1225672496
Name:CONNELLY, KATHLEEN BETH
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:BETH
Last Name:CONNELLY
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 1:1505 MEAD LN
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-1466
Mailing Address - Country:US
Mailing Address - Phone:405-410-4147
Mailing Address - Fax:
Practice Address - Street 1:921 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5007
Practice Address - Country:US
Practice Address - Phone:405-456-3859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0040928163W00000X
102399246X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246X00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist Cardiovascular
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
102399OtherARDMS
OKR0040928OtherOK BOARD OF NURSING