Provider Demographics
NPI:1679918890
Name:CONNELLY, KELLY ANN (RN)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7312 67TH RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-2627
Mailing Address - Country:US
Mailing Address - Phone:347-666-1078
Mailing Address - Fax:
Practice Address - Street 1:7312 67TH RD
Practice Address - Street 2:
Practice Address - City:MIDDLE VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11379-2627
Practice Address - Country:US
Practice Address - Phone:347-666-1078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY658866163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse