Provider Demographics
NPI:1346625183
Name:CONNOLLY, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
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 1:14502 W MEEKER BLVD
Mailing Address - Street 2:BANNER DEL E. WEBB EMERGENCY DEPT
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-5282
Mailing Address - Country:US
Mailing Address - Phone:623-524-4067
Mailing Address - Fax:623-524-4182
Practice Address - Street 1:14502 W MEEKER BLVD
Practice Address - Street 2:BANNER DEL E. WEBB EMERGENCY DEPT
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5282
Practice Address - Country:US
Practice Address - Phone:623-524-4067
Practice Address - Fax:623-524-4182
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27-1369141390200000X
AZ6176363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZIN PROCESSOtherTHE MUTUAL