Basic Information
| Provider Information | |||||||||
| NPI: | 1316028608 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONNOLLY | ||||||||
| FirstName: | DOROTHEA | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 EAST PENN SQUARE | ||||||||
| Address2: | THE WANAMAKER BUILDING, 9TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259300 | ||||||||
| FaxNumber: | 2674259331 | ||||||||
| Practice Location | |||||||||
| Address1: | 34TH STREET AND CIVIC CENTER BOULEVARD | ||||||||
| Address2: | SUITE 9329 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901858 | ||||||||
| FaxNumber: | 2155901415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 04/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN291799L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 177562EJL | 01 | PA | MEDICARE PTAN | OTHER |