Provider Demographics
NPI:1427091917
Name:CONNELLY, KATIE A (CNM)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:A
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 BOWNE AVE
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-1659
Mailing Address - Country:US
Mailing Address - Phone:732-616-7468
Mailing Address - Fax:
Practice Address - Street 1:101 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5020
Practice Address - Country:US
Practice Address - Phone:732-942-4442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25ME00038700367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife