Provider Demographics
NPI:1790093391
Name:CONNELLY, CAROLINE L (FNP)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:L
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2620 E BARNETT RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8344
Mailing Address - Country:US
Mailing Address - Phone:541-789-8176
Mailing Address - Fax:541-789-2558
Practice Address - Street 1:691 MURPHY RD
Practice Address - Street 2:SUITE 107
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4346
Practice Address - Country:US
Practice Address - Phone:541-789-6460
Practice Address - Fax:541-789-6461
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR201050177NP363LF0000X
OR201020177NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500629732Medicaid
ORR104443Medicare PIN
ORR156535Medicare PIN