Provider Demographics
NPI:1619996477
Name:CONNOLLY, HEATHER LANE (DC)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:LANE
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:HEATHER
Other - Middle Name:LANE
Other - Last Name:JEROME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:338 RIVER ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05602-8242
Mailing Address - Country:US
Mailing Address - Phone:802-225-8958
Mailing Address - Fax:
Practice Address - Street 1:338 RIVER ST
Practice Address - Street 2:SUITE 8
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-8242
Practice Address - Country:US
Practice Address - Phone:802-225-8958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT006-0001133111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT59831OtherBC PROVIDER ID
VTVN3297Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID