Provider Demographics
NPI:1578073946
Name:CONNOLLY, PEGE
Entity Type:Individual
Prefix:
First Name:PEGE
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 IRENE AVE. P.O. BOX 1
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:MN
Mailing Address - Zip Code:56455
Mailing Address - Country:US
Mailing Address - Phone:218-546-6242
Mailing Address - Fax:218-772-0142
Practice Address - Street 1:317 IRENE AVE.
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:MN
Practice Address - Zip Code:56455
Practice Address - Country:US
Practice Address - Phone:218-546-6242
Practice Address - Fax:218-772-0142
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-107553-9163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1669628921Medicaid