Provider Demographics
NPI:1528090297
Name:CONNELLY, JEAN C (RN, ACNP)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:C
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:RN, ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 WESTPARK WAY STE 210
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-3742
Mailing Address - Country:US
Mailing Address - Phone:682-236-3656
Mailing Address - Fax:855-813-9308
Practice Address - Street 1:251 WESTPARK WAY STE 210
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-3742
Practice Address - Country:US
Practice Address - Phone:682-236-3656
Practice Address - Fax:855-813-9308
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX456277363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX088288803Medicaid
TN088288805Medicaid
TX088288804Medicaid
TX088288806Medicaid
TX088288806Medicaid
TX8L24838Medicare PIN
TX8L24836Medicare PIN
TXTXB122025Medicare PIN
TX8L24848Medicare PIN
TX088288804Medicaid