Provider Demographics
NPI:1477532851
Name:CONNELLY, ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:CONNELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:5008 BRITTONFIELD PKWY
Mailing Address - Street 2:SUITE 700
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9248
Mailing Address - Country:US
Mailing Address - Phone:315-472-7504
Mailing Address - Fax:315-479-8639
Practice Address - Street 1:5008 BRITTONFIELD PKWY
Practice Address - Street 2:SUITE 700
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057
Practice Address - Country:US
Practice Address - Phone:315-472-7504
Practice Address - Fax:315-479-8639
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301277-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02364905Medicaid
NYBB3757Medicare PIN