Provider Demographics
NPI:1639656085
Name:CONNELY, STEPHANIE NOELLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:NOELLE
Last Name:CONNELY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17700 E 39TH ST S
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6725
Mailing Address - Country:US
Mailing Address - Phone:163-930-2508
Mailing Address - Fax:
Practice Address - Street 1:2577 MAIN AVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301
Practice Address - Country:US
Practice Address - Phone:970-247-8382
Practice Address - Fax:970-259-4403
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018017096363A00000X
NY022356-1363A00000X
COPA.0005871363AM0700X
KS15-02568363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE