Provider Demographics
NPI:1700498698
Name:CONNELLY, ANASTASIA
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 KNOLL PARK LN
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-1757
Mailing Address - Country:US
Mailing Address - Phone:909-936-7422
Mailing Address - Fax:
Practice Address - Street 1:1461 KNOLL PARK LN
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-1757
Practice Address - Country:US
Practice Address - Phone:909-936-7422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95073525163W00000X
AZ256741163W00000X, 367500000X
TX1136805367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse