Healthcare Provider Details

I. General information

NPI: 1093322596
Provider Name (Legal Business Name): STACY CONNELLY RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 SEMINARY RD
ALEXANDRIA VA
22304-1535
US

IV. Provider business mailing address

4924 25TH ST S
ARLINGTON VA
22206-1051
US

V. Phone/Fax

Practice location:
  • Phone: 703-504-7867
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberR174110
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: