1992876064 NPI number — MS. TERESA JOSEPHINE CONNELLY MA

Table of content: JAZMINE FELICIANO (NPI 1376328575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992876064 NPI number — MS. TERESA JOSEPHINE CONNELLY MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNELLY
Provider First Name:
TERESA
Provider Middle Name:
JOSEPHINE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992876064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
277 COON RAPIDS BLVD NW
Provider Second Line Business Mailing Address:
SUITE 308
Provider Business Mailing Address City Name:
COON RAPIDS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55433-5843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-717-4979
Provider Business Mailing Address Fax Number:
763-717-4954

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1874 3RD ST SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW BRIGHTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-717-4979
Provider Business Practice Location Address Fax Number:
763-717-4954
Provider Enumeration Date:
11/12/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TA0400X , with the licence number:  LP2332 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TB0200X , with the licence number: LP2332 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TF0000X , with the licence number: LP2332 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TP2701X , with the licence number: LP2332 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: LP2332 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: LP2332 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X , with the licence number: LP2332 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: LP2332 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 57348CO . This is a "BLUECROSS PROVIDER NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".