Provider Demographics
NPI:1417551268
Name:CONNOLLY, MARILYN GRAY (APRN)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:GRAY
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARILYN
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:151 SOUTHHALL LN STE 300
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7172
Practice Address - Country:US
Practice Address - Phone:407-917-7293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000026941363L00000X, 363LG0600X, 363LP2300X, 363L00000X
COC-APN.0001934-C-NP363L00000X, 363LG0600X, 363L00000X
FLAPRN11011911363LA2200X
FL11011911363LP2300X, 363L00000X, 363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120071900Medicaid
FLUDET1OtherBLUE CROSS BLUE SHIELD