MEDICARE: NICOLE PATRICIA CONNOLLY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	0101226970	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457344962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE PATRICIA CONNOLLY MD

Provider Business Mailing Address
First Line	:	PO BOX 17334
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21297-1334
Country	:	US
Telephone Number	:	703-443-6717
Fax Number	:	703-443-8643

Provider Business Practice Location Address
First Line	:	19500 SANDRIDGE WAY
Second Line	:	SUITE 110
City	:	LEESBURG
State	:	VA
Zip	:	20176-6821
Country	:	US
Telephone Number	:	703-723-7337
Fax Number	:	703-723-6848

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	10/15/2010

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