Provider Demographics
NPI:1235317702
Name:CONNELLY, LIESL MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:LIESL
Middle Name:MARIE
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 W. RALPH HALL PKWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-6662
Mailing Address - Country:US
Mailing Address - Phone:972-771-9081
Mailing Address - Fax:
Practice Address - Street 1:1005 W. RALPH HALL PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-6662
Practice Address - Country:US
Practice Address - Phone:972-771-9081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05675363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical