Provider Demographics
NPI:1376810317
Name:CONNOLLY, ERIC (LPN)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 NORWAY PINE DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-4206
Mailing Address - Country:US
Mailing Address - Phone:516-806-7686
Mailing Address - Fax:631-569-2209
Practice Address - Street 1:5 NORWAY PINE DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-4206
Practice Address - Country:US
Practice Address - Phone:516-806-7686
Practice Address - Fax:631-569-2209
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308390164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse