1104419209 NPI number — MS. KELLIE ANN CONNELLY RETAIL PROVIDER

Table of content: MS. KELLIE ANN CONNELLY RETAIL PROVIDER (NPI 1104419209)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104419209 NPI number — MS. KELLIE ANN CONNELLY RETAIL PROVIDER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNELLY
Provider First Name:
KELLIE
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RETAIL PROVIDER
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:
1104419209
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
08/17/2022
NPI Reactivation Date:
09/12/2022

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
798 MEADOWDALE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTAMONT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12009-4710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-858-8129
Provider Business Mailing Address Fax Number:
518-861-6840

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
798 MEADOWDALE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTAMONT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12009-4710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-858-8129
Provider Business Practice Location Address Fax Number:
518-861-6840
Provider Enumeration Date:
02/19/2021

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: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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