Healthcare Provider Details

I. General information

NPI: 1124294145
Provider Name (Legal Business Name): CONNERY LEE FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7761 GARDEN GROVE BLVD
GARDEN GROVE CA
92841-4200
US

IV. Provider business mailing address

21520 PIONEER BLVD STE 110
HAWAIIAN GARDENS CA
90716-2604
US

V. Phone/Fax

Practice location:
  • Phone: 714-898-8888
  • Fax: 714-901-7580
Mailing address:
  • Phone: 562-865-3644
  • Fax: 562-924-3860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN 614482
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17357
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: