Provider Demographics
NPI:1063804623
Name:CONNOLLY, MAUREEN N
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:N
Last Name:CONNOLLY
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 1:522 BUCHANAN BLVD
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-5355
Mailing Address - Country:US
Mailing Address - Phone:732-674-2295
Mailing Address - Fax:
Practice Address - Street 1:130 SPEEDWELL AVE
Practice Address - Street 2:
Practice Address - City:MORRIS PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07950-2315
Practice Address - Country:US
Practice Address - Phone:862-242-8053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-19
Last Update Date:2015-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00533000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily