Provider Demographics
NPI:1972933372
Name:CONNOLLY, DANIEL (CRNA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8378 DUNMORE DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-4496
Mailing Address - Country:US
Mailing Address - Phone:630-254-9624
Mailing Address - Fax:
Practice Address - Street 1:2233 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-8151
Practice Address - Country:US
Practice Address - Phone:312-770-2172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-21
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.010854367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered