Provider Demographics
NPI:1659614600
Name:CONQUEST, ELIZABETH (ATC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:CONQUEST
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 RIVERSIDE DR APT 217
Mailing Address - Street 2:
Mailing Address - City:HOLLY HILL
Mailing Address - State:FL
Mailing Address - Zip Code:32117-3767
Mailing Address - Country:US
Mailing Address - Phone:386-295-2669
Mailing Address - Fax:
Practice Address - Street 1:311 RIVERSIDE DR APT 217
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-3767
Practice Address - Country:US
Practice Address - Phone:386-295-2669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL28982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer