Provider Demographics
NPI:1417028366
Name:CONNOLLY, KENNETH WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2538 CR 852
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75071-6897
Mailing Address - Country:US
Mailing Address - Phone:214-906-3824
Mailing Address - Fax:214-733-8858
Practice Address - Street 1:2479 COUNTY ROAD 856
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-6894
Practice Address - Country:US
Practice Address - Phone:214-906-3824
Practice Address - Fax:214-733-8858
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4949111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T78953Medicare UPIN
TX80730FMedicare ID - Type Unspecified