Provider Demographics
NPI:1659630887
Name:CONNERY, BRIAN RICHARD (LPN)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:RICHARD
Last Name:CONNERY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 PRESTIGE CT
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-9390
Mailing Address - Country:US
Mailing Address - Phone:608-884-2867
Mailing Address - Fax:
Practice Address - Street 1:555 PRESTIGE CT
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-9390
Practice Address - Country:US
Practice Address - Phone:608-884-2867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI315519-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse