Healthcare Provider Details

I. General information

NPI: 1902925266
Provider Name (Legal Business Name): KARIN SUE CONNOLLY ADULT NURSE PRACTITI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 W 3RD ST
DAYTON OH
45428-9000
US

IV. Provider business mailing address

6439 GARNERS FERRY RD. (WM, JENNINGS BRYAN DORN VAMC)
COLUMBIA SC
29209
US

V. Phone/Fax

Practice location:
  • Phone: 513-891-3100
  • Fax: 513-487-6052
Mailing address:
  • Phone: 803-776-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number143132
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberARNP9283958
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: