Jacob Connelly
Individual provider Active NPI Family Nurse Practitioner · Los Alamos, NM
NPI 1790147593 · NPPES record last updated Aug 26, 2025
Key facts
- NPI
- 1790147593
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Nurse Practitioner 363LF0000X
- License
- 11005429 (FL)
- Practice address
- 3917 West Rd Ste A3917
Los Alamos, NM 87544-2275 - Phone
- (505) 661-8959
- Fax
- (505) 661-8916
- NPI assigned
- Mar 22, 2016
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 2
Hospital & facility affiliations 1
Medicare Care Compare profile
- Specialty
- Nurse Practitioner
- Education
- Other, 2019
- Medicare assignment
- May accept Medicare assignment
Practice addresses (Care Compare)
408 Cleveland Ave
Lehigh Acres, FL 33972-4119
Hospital & facility affiliations
- Los Alamos Medical Center
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No · DME: Yes · Home health: No · Power mobility devices: Yes · Hospice: No
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Certified Nurse Practitioner, Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| RN 9409391 | FL | MD | Registered Nurse |
| 11005429 | FL | MD | Family Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Medical Associates of Northern New Mexico | Current |
Accepting new patients | |
| Reliant Acute Care, LLC | Current |
Accepting new patients |
Locations
5781 Lee Blvd
Unit 105
Lehigh Acres, FL 33971
Phone (239) 265-9760
3917 West Rd
Ste A
Los Alamos, NM 87544
Phone (505) 661-8900
Interoperability endpoints
- https://fhir4.healow.com/fhir/r4/AAGADA
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Nurse | 163W00000X | RN 9409391 | FL | |
| Family Nurse Practitioner | 363LF0000X | 11005429 | FL | Yes |
Addresses
Primary practice location
3917 West Rd Ste A3917
Los Alamos, NM 87544-2275
Mailing address
3917 West Rd Ste a
Los Alamos, NM 87544-2292
Phone (505) 661-8959
Other practice location 1
737 Cape Coral Pkwy E
Cape Coral, FL 33904-8551
Phone (239) 542-0512
Other practice location 2
8291 Dani Dr Ste 100
Fort Myers, FL 33966-8021
Phone (239) 931-6049
Other providers in Los Alamos, NM
- John W Collings
- Allison Coltisor
- Marie A Combs
- Patricia Combs
- Carina Andrea Condado
- Josh M Connole
- Copper Canyon Wellness, LLC
- Corazon Behavioral Health Services Inc
- Corazon del Oso Healthcare, LLC
- Clorinda Leann Cordova
All providers in Los Alamos, NM · Family Nurse Practitioner in New Mexico
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 26, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.