Healthcare Provider Details

I. General information

NPI: 1023364262
Provider Name (Legal Business Name): GINA M. CONNOLLY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NAVARRE PL STE 6600
SOUTH BEND IN
46601-1173
US

IV. Provider business mailing address

710 N NILES AVE
SOUTH BEND IN
46617-1924
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-8800
  • Fax: 574-647-8896
Mailing address:
  • Phone: 574-647-1610
  • Fax: 574-237-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71004080A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71004080A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: