Provider Demographics
NPI:1497092241
Name:CONNELLY, NANCY L (PT)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:L
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1597
Mailing Address - Country:US
Mailing Address - Phone:618-910-2709
Mailing Address - Fax:618-282-3596
Practice Address - Street 1:325 SPRING ST
Practice Address - Street 2:
Practice Address - City:RED BUD
Practice Address - State:IL
Practice Address - Zip Code:62278-1105
Practice Address - Country:US
Practice Address - Phone:618-282-5172
Practice Address - Fax:618-282-3596
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070007904225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist