Healthcare Provider Details

I. General information

NPI: 1093181364
Provider Name (Legal Business Name): KRISTEN CONNOLLY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2015
Last Update Date: 08/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 LIMITED LN NW SUITE B
OLYMPIA WA
98502-2638
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 360-709-0700
  • Fax:
Mailing address:
  • Phone: 630-296-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT30121
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number60662111
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: