Provider Demographics
NPI:1912518150
Name:CONNELL, NICOLE LYNN (RDH)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:CONNELL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 EAST BOSTON AVE.
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:IL
Mailing Address - Zip Code:61462
Mailing Address - Country:US
Mailing Address - Phone:309-536-0134
Mailing Address - Fax:
Practice Address - Street 1:204 HWY 164 EAST
Practice Address - Street 2:
Practice Address - City:OQUAWKA
Practice Address - State:IL
Practice Address - Zip Code:61469
Practice Address - Country:US
Practice Address - Phone:309-867-2770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.011296124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist