Provider Demographics
NPI:1063763878
Name:CONNELLY, CHRISTINA (LPN)
Entity type:Individual
Prefix:MS
First Name:CHRISTINA
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 N MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-1528
Mailing Address - Country:US
Mailing Address - Phone:517-278-1926
Mailing Address - Fax:517-278-6555
Practice Address - Street 1:265 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-1528
Practice Address - Country:US
Practice Address - Phone:517-278-1926
Practice Address - Fax:517-278-6555
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703038270164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI164W00000XMedicaid