Provider Demographics
NPI:1558948109
Name:CONNOLLY, NICOLE MARIE (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVENUE
Mailing Address - Street 2:ML 7009
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3333 BURNET AVENUE
Practice Address - Street 2:ML 7009
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3039
Practice Address - Country:US
Practice Address - Phone:513-636-4830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-28
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.150321208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program