Provider Demographics
NPI:1568722478
Name:CONNELLY, PATRICIA MARY (HHA, PCA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MARY
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:HHA, PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 GOOSEBERRY RD
Mailing Address - Street 2:
Mailing Address - City:MASTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11951-6335
Mailing Address - Country:US
Mailing Address - Phone:631-316-9760
Mailing Address - Fax:
Practice Address - Street 1:27 GOOSEBERRY RD
Practice Address - Street 2:
Practice Address - City:MASTIC BEACH
Practice Address - State:NY
Practice Address - Zip Code:11951-6335
Practice Address - Country:US
Practice Address - Phone:631-316-9760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3747P1801X
NY00310022374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant