Healthcare Provider Details

I. General information

NPI: 1427091917
Provider Name (Legal Business Name): KATIE A CONNELLY CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 PROSPECT ST
LAKEWOOD NJ
08701-5020
US

IV. Provider business mailing address

43 BOWNE AVE
FREEHOLD NJ
07728-1659
US

V. Phone/Fax

Practice location:
  • Phone: 732-942-4442
  • Fax:
Mailing address:
  • Phone: 732-616-7468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number25ME00038700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: