Healthcare Provider Details

I. General information

NPI: 1215479894
Provider Name (Legal Business Name): EMILY KRISTIN CONNELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 SUTTON ST
NORTH ANDOVER MA
01845-1680
US

IV. Provider business mailing address

220 SUTTON ST
NORTH ANDOVER MA
01845-1680
US

V. Phone/Fax

Practice location:
  • Phone: 978-682-7009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT012517
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: