Provider Demographics
NPI:1508486960
Name:CONNELLY, BRIAN E
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:E
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5522 18TH ST
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-4518
Mailing Address - Country:US
Mailing Address - Phone:813-454-4993
Mailing Address - Fax:
Practice Address - Street 1:13100 FORT KING RD
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-5294
Practice Address - Country:US
Practice Address - Phone:352-521-1175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-25
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist