Provider Demographics
NPI:1932514973
Name:CONNOLLY, KIAH
Entity Type:Individual
Prefix:
First Name:KIAH
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIAH
Other - Middle Name:
Other - Last Name:BERTOGLIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3700 ARROYO AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-7105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3700 ARROYO AVE
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-7105
Practice Address - Country:US
Practice Address - Phone:916-709-6485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-29
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA134971207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine