Provider Demographics
NPI:1376285510
Name:CONNELLY, MARGARET M
Entity Type:Individual
Prefix:
First Name:MARGARET
Middle Name:M
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 1:2164 AVALON VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2692
Mailing Address - Country:US
Mailing Address - Phone:314-277-8075
Mailing Address - Fax:
Practice Address - Street 1:13861 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-4503
Practice Address - Country:US
Practice Address - Phone:636-932-8029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-08
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022012581363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant