Provider Demographics
NPI:1356505697
Name:CONNOLLY, LISA ANN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-8996
Mailing Address - Country:US
Mailing Address - Phone:207-883-1211
Mailing Address - Fax:
Practice Address - Street 1:7 PLAZA DR
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-8996
Practice Address - Country:US
Practice Address - Phone:207-883-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME02-25-20082251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics