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NPI Code Detail

MEDICARE: MRS. SALLY POWELL CONNELLA PT, DPT

MEDICARE: MRS. SALLY POWELL CONNELLA PT, DPT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist08043LA

General Provider Information

NPI Number : 1164717526
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. SALLY POWELL CONNELLA PT, DPT
Provider Business Mailing Address
First Line : 2522 E 70TH ST
Second Line :
City : SHREVEPORT
State : LA
Zip : 71105-4002
Country : US
Telephone Number : 318-795-3388
Fax Number : 318-795-3399
Provider Business Practice Location Address
First Line : 2522 E 70TH ST
Second Line :
City : SHREVEPORT
State : LA
Zip : 71105-4002
Country : US
Telephone Number : 318-795-3388
Fax Number : 318-795-3399
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/14/2011
Last Update Date : 06/14/2011

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