Provider Demographics
NPI:1710968300
Name:CONNALLY, TINA ANNETTE (RN)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:ANNETTE
Last Name:CONNALLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:TINA
Other - Middle Name:ANNETTE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:18TH MEDCOM
Mailing Address - Street 2:ATTN: DCCS-QM (CREDENTIALS)
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205-0054
Mailing Address - Country:KR
Mailing Address - Phone:0118227-916-6027
Mailing Address - Fax:0118227-917-8110
Practice Address - Street 1:HHC, 121ST GENERAL HOSPITAL
Practice Address - Street 2:ATTN: DON/ICU
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96205
Practice Address - Country:KR
Practice Address - Phone:0118227-917-5068
Practice Address - Fax:0118227-917-3000
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR28975163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse