Healthcare Provider Details

I. General information

NPI: 1528498623
Provider Name (Legal Business Name): SHELBY CONNELLY L.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2013
Last Update Date: 12/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 WILDWOOD RD
COLTON NY
13625-3204
US

IV. Provider business mailing address

2 WILDWOOD RD
COLTON NY
13625-3204
US

V. Phone/Fax

Practice location:
  • Phone: 315-262-2622
  • Fax:
Mailing address:
  • Phone: 315-262-2622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number001058
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: