Provider Demographics
NPI:1326661323
Name:CONNELLY, KIM LEA
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:LEA
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:LEA
Other - Last Name:VAN ZEELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2276 DOLLAR RD
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-9712
Mailing Address - Country:US
Mailing Address - Phone:920-737-3601
Mailing Address - Fax:
Practice Address - Street 1:1700 CHICAGO ST
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-3418
Practice Address - Country:US
Practice Address - Phone:920-337-1032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI123148-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse