Provider Demographics
NPI:1356526115
Name:CONNOLLY, CONNIE LOU (RN)
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:LOU
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:CONNIE
Other - Middle Name:LOU
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:162 GROVE ST STE J
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-2652
Mailing Address - Country:US
Mailing Address - Phone:760-873-6533
Mailing Address - Fax:
Practice Address - Street 1:162 GROVE ST STE J
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-2652
Practice Address - Country:US
Practice Address - Phone:760-873-6533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-29
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO68232163WP2201X
CA815310163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care