Provider Demographics
NPI:1790758472
Name:CONNELL, LAURIE K (CRNA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:K
Last Name:CONNELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 817737
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33081-1737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2120 NW 107TH TER
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33322-3418
Practice Address - Country:US
Practice Address - Phone:954-741-0636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-11
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3278662367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306485900Medicaid
FLG3586YMedicare ID - Type Unspecified
FLG3586ZMedicare ID - Type Unspecified