Provider Demographics
NPI:1639101496
Name:WELLS, CONNIE W (ATC, LAT, LMBT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:W
Last Name:WELLS
Suffix:
Gender:F
Credentials:ATC, LAT, LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 GARNER CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:NC
Mailing Address - Zip Code:28365-6146
Mailing Address - Country:US
Mailing Address - Phone:919-658-0476
Mailing Address - Fax:
Practice Address - Street 1:599 GARNER CHAPEL RD
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365-6146
Practice Address - Country:US
Practice Address - Phone:919-658-0476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCERTIFICATION146N00000X
NC05802255A2300X
NC724225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist