1407843220 NPI number — DR. LAURIE LYNN CONNOLLY M.D.

Table of content: DR. LAURIE LYNN CONNOLLY M.D. (NPI 1407843220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407843220 NPI number — DR. LAURIE LYNN CONNOLLY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONNOLLY
Provider First Name:
LAURIE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CONNOLLY-CROSS
Provider Other First Name:
LAURIE
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1407843220
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1002 LINCOLN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-386-4192
Provider Business Mailing Address Fax Number:
515-386-3448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1002 LINCOLN WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-386-4192
Provider Business Practice Location Address Fax Number:
515-386-3448
Provider Enumeration Date:
10/06/2005

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: 207Q00000X , with the licence number:  33622 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2197772 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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