Provider Demographics
NPI:1730545534
Name:CONNELLY, MELISSA SUE (DNP, ARNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:DNP, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-358-0011
Mailing Address - Fax:515-358-0099
Practice Address - Street 1:1111 6TH AVE STE A100
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-2610
Practice Address - Country:US
Practice Address - Phone:515-358-0011
Practice Address - Fax:515-358-0099
Is Sole Proprietor?:No
Enumeration Date:2016-01-08
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP015406363LF0000X
IAA163840363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103513675Medicaid