Healthcare Provider Details

I. General information

NPI: 1790093391
Provider Name (Legal Business Name): CAROLINE L CONNELLY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

691 MURPHY RD SUITE 107
MEDFORD OR
97504-4346
US

IV. Provider business mailing address

2620 E BARNETT RD SUITE H
MEDFORD OR
97504-8344
US

V. Phone/Fax

Practice location:
  • Phone: 541-789-6460
  • Fax: 541-789-6461
Mailing address:
  • Phone: 541-789-8176
  • Fax: 541-789-2558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201050177NP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number201020177NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: