Provider Demographics
NPI:1497189757
Name:CONNELL, SUSAN K
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:CONNELL
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 1:1060 GAFFNEY RD STOP 7440
Mailing Address - Street 2:
Mailing Address - City:FT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-5007
Mailing Address - Country:US
Mailing Address - Phone:907-580-1656
Mailing Address - Fax:
Practice Address - Street 1:1060 GAFFNEY RD STOP 7440
Practice Address - Street 2:
Practice Address - City:FT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-5007
Practice Address - Country:US
Practice Address - Phone:907-580-1656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT23553225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist