Provider Demographics
NPI:1104419209
Name:CONNELLY, KELLIE ANN (RETAIL PROVIDER)
Entity type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:ANN
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:RETAIL PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:798 MEADOWDALE RD
Mailing Address - Street 2:
Mailing Address - City:ALTAMONT
Mailing Address - State:NY
Mailing Address - Zip Code:12009-4710
Mailing Address - Country:US
Mailing Address - Phone:518-858-8129
Mailing Address - Fax:518-861-6840
Practice Address - Street 1:798 MEADOWDALE RD
Practice Address - Street 2:
Practice Address - City:ALTAMONT
Practice Address - State:NY
Practice Address - Zip Code:12009-4710
Practice Address - Country:US
Practice Address - Phone:518-858-8129
Practice Address - Fax:518-861-6840
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2022-09-12
Deactivation Date:2022-08-17
Deactivation Code:
Reactivation Date:2022-09-12
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies