Provider Demographics
NPI:1255667309
Name:CONNELLY, MARCIA DIANNE (LAC)
Entity Type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:DIANNE
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1476
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95061-1476
Mailing Address - Country:US
Mailing Address - Phone:831-818-7051
Mailing Address - Fax:
Practice Address - Street 1:1900 GARDEN RD
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-5373
Practice Address - Country:US
Practice Address - Phone:831-818-7051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13176171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist