=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346711603
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE KIRSTEN CONELY PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2018
-----------------------------------------------------
Last Update Date | 12/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11093 SW LEWIS MEMORIAL DR
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22427-2174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-285-6200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 ROSE HILL FARM DR
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22556-6402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-446-3066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 0202208518
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------