Healthcare Provider Details

I. General information

NPI: 1346625183
Provider Name (Legal Business Name): COURTNEY CONNOLLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14502 W MEEKER BLVD BANNER DEL E. WEBB EMERGENCY DEPT
SUN CITY WEST AZ
85375-5282
US

IV. Provider business mailing address

14502 W MEEKER BLVD BANNER DEL E. WEBB EMERGENCY DEPT
SUN CITY WEST AZ
85375-5282
US

V. Phone/Fax

Practice location:
  • Phone: 623-524-4067
  • Fax: 623-524-4182
Mailing address:
  • Phone: 623-524-4067
  • Fax: 623-524-4182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number6176
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number27-1369141
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: