Provider Demographics
NPI:1477175198
Name:CONNOLLY, MARISSA ANNE (DO)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANNE
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:973 FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93246-4900
Mailing Address - Country:US
Mailing Address - Phone:559-998-4481
Mailing Address - Fax:
Practice Address - Street 1:973 FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:LEMOORE
Practice Address - State:CA
Practice Address - Zip Code:93246-4900
Practice Address - Country:US
Practice Address - Phone:559-998-4481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01022067692084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry