Healthcare Provider Details

I. General information

NPI: 1609838564
Provider Name (Legal Business Name): SANDRA MAUREEN CONNELL OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 DELLWOOD ST S
CAMBRIDGE MN
55008-1920
US

IV. Provider business mailing address

2925 CHICAGO AVE MR 10809
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 763-689-7700
  • Fax:
Mailing address:
  • Phone: 612-262-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2678
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: