Healthcare Provider Details

I. General information

NPI: 1609527068
Provider Name (Legal Business Name): BRITTANY L CONNELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 E KESSLER BLVD
LONGVIEW WA
98632-1842
US

IV. Provider business mailing address

5318 NE 114TH ST
VANCOUVER WA
98686-4529
US

V. Phone/Fax

Practice location:
  • Phone: 360-747-5800
  • Fax: 360-575-3846
Mailing address:
  • Phone: 360-989-5408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2202
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61308534
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: