Healthcare Provider Details

I. General information

NPI: 1891172821
Provider Name (Legal Business Name): MS. NICHOLE JEAN CONNOLLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 FORTUNE BLVD
MILFORD MA
01757-1750
US

IV. Provider business mailing address

3228 SARDENIA TER
DELTONA FL
32738-6934
US

V. Phone/Fax

Practice location:
  • Phone: 774-200-6879
  • Fax:
Mailing address:
  • Phone: 774-200-6879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: