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General NPI Number Information
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NPI Number | 1033106331
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Entity Type | Individual
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Provider Name | AMY G. CONNOLLY PA-C
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Gender | Female
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Dates
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Enumeration Date | 10/01/2005
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Last Update Date | 09/11/2024
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Provider Practice Location Address
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Address Line | 22255 GREENFIELD RD STE 590
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City | SOUTHFIELD
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State | MI
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Zip | 48075-3734
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Country | US
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Telephone | 248-849-4990
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Fax | 248-849-4991
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Provider Business Mailing Address
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Address Line | 7348 RAFFORD LN
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City | WEST BLOOMFIELD
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State | MI
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Zip | 48322-3190
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Country | US
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Telephone | 248-592-0733
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601002695
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License Number State | MI
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