Provider Demographics
NPI:1770170342
Name:CONNELL, CODY WAYNE
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:WAYNE
Last Name:CONNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 WATERS EDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:GA
Mailing Address - Zip Code:30179-5830
Mailing Address - Country:US
Mailing Address - Phone:256-591-6459
Mailing Address - Fax:
Practice Address - Street 1:1365 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-3818
Practice Address - Country:US
Practice Address - Phone:404-778-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN261203363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty