Provider Demographics
NPI:1912614280
Name:CONNELLY, MARY CLAIRE
Entity Type:Individual
Prefix:
First Name:MARY CLAIRE
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 1:747 RALPH MCGILL BLVD NE UNIT 1131
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1134
Mailing Address - Country:US
Mailing Address - Phone:301-832-8464
Mailing Address - Fax:
Practice Address - Street 1:1520 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-4201
Practice Address - Country:US
Practice Address - Phone:404-727-7980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN288819163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory