Healthcare Provider Details

I. General information

NPI: 1902831258
Provider Name (Legal Business Name): ANDREA J MCCONNELL ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 E INDIANA ST STE 102
EVANSVILLE IN
47715-2794
US

IV. Provider business mailing address

7300 E INDIANA ST STE 102
EVANSVILLE IN
47715-2794
US

V. Phone/Fax

Practice location:
  • Phone: 812-476-0409
  • Fax: 812-476-1016
Mailing address:
  • Phone: 812-476-0409
  • Fax: 812-476-1016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000730A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: