Healthcare Provider Details

I. General information

NPI: 1285421297
Provider Name (Legal Business Name): NICOLE MCCONNELL OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16918 W BETH DR
GOODYEAR AZ
85338-4740
US

IV. Provider business mailing address

7071 N 138TH AVE BLDG 1540
GLENDALE AZ
85307-2006
US

V. Phone/Fax

Practice location:
  • Phone: 623-606-1510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-002943
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: