Provider Demographics
NPI:1154676989
Name:CONLON, MARYELLA JANE (DPT)
Entity Type:Individual
Prefix:
First Name:MARYELLA
Middle Name:JANE
Last Name:CONLON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MARYELLA
Other - Middle Name:JANE
Other - Last Name:CONLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:172 E HARBOR
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-3553
Mailing Address - Country:US
Mailing Address - Phone:214-682-6532
Mailing Address - Fax:
Practice Address - Street 1:172 E HARBOR
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-3553
Practice Address - Country:US
Practice Address - Phone:214-682-6532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11970225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200442370AMedicaid
OK200442370AMedicaid