Provider Demographics
NPI:1417384983
Name:CONNOLLY, CARMEN DANIELA (PA)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:DANIELA
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:2101 ATLANTIC SHORES BLVD
Mailing Address - Street 2:APT 216
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-2897
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:603 N FLAMINGO RD
Practice Address - Street 2:SUITE 357
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1023
Practice Address - Country:US
Practice Address - Phone:954-450-8488
Practice Address - Fax:954-450-8860
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
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Provider Licenses
StateLicense IDTaxonomies
FLPA9107411363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant