Provider Demographics
NPI:1710428461
Name:CONNELLY, LISA (FNP-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-3307
Mailing Address - Country:US
Mailing Address - Phone:620-251-2400
Mailing Address - Fax:620-251-1619
Practice Address - Street 1:420 W 15TH AVE
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-5367
Practice Address - Country:US
Practice Address - Phone:620-251-2400
Practice Address - Fax:620-251-1619
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS77645363LF0000X, 363LF0000X
KS14-123482-101163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse