Provider Demographics
NPI:1659780930
Name:CONNOLLY, ANGELITA (MOTL)
Entity Type:Individual
Prefix:
First Name:ANGELITA
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:MOTL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2455 LARKEY LN
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2910
Mailing Address - Country:US
Mailing Address - Phone:925-848-4751
Mailing Address - Fax:
Practice Address - Street 1:2455 LARKEY LN
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-2910
Practice Address - Country:US
Practice Address - Phone:925-848-4751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT1504172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker