Provider Demographics
NPI:1255398558
Name:CONNOLLY, LAURA LEE (PAC)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:LEE
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WESTBROOK CORPORATE CTR
Mailing Address - Street 2:STE 1000
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5703
Mailing Address - Country:US
Mailing Address - Phone:708-343-3566
Mailing Address - Fax:708-343-9235
Practice Address - Street 1:3 WESTBROOK CORPORATE CTR
Practice Address - Street 2:STE 1000
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-5703
Practice Address - Country:US
Practice Address - Phone:708-343-3566
Practice Address - Fax:708-343-9235
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002150363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085002150Medicaid
Q03670Medicare UPIN
ILK02633Medicare ID - Type Unspecified
IL085002150Medicaid