Provider Demographics
NPI:1407843220
Name:CONNOLLY, LAURIE LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:LYNN
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAURIE
Other - Middle Name:LYNN
Other - Last Name:CONNOLLY-CROSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1002 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:IA
Mailing Address - Zip Code:50129
Mailing Address - Country:US
Mailing Address - Phone:515-386-4192
Mailing Address - Fax:515-386-3448
Practice Address - Street 1:1002 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:IA
Practice Address - Zip Code:50129
Practice Address - Country:US
Practice Address - Phone:515-386-4192
Practice Address - Fax:515-386-3448
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2197772Medicaid
IAI21666Medicare PIN
IA2197772Medicaid