Provider Demographics
NPI:1750497822
Name:CONNELLY, ANGELA CORVERA (BS PT)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:CORVERA
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:BS PT
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:EGNISABAN
Other - Last Name:CORVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS PT
Mailing Address - Street 1:2701 NW VAUGHN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2701 NW VAUGHN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5311
Practice Address - Country:US
Practice Address - Phone:503-721-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4705225100000X
CA15088225100000X
CO4863225100000X
WAPT00009440225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist