Provider Demographics
NPI:1790714434
Name:CONNOLLY, LAUREN ELISE (PT)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELISE
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:ELISE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:199 14TH ST NE
Mailing Address - Street 2:#2803
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3643
Mailing Address - Country:US
Mailing Address - Phone:770-499-9918
Mailing Address - Fax:770-792-8276
Practice Address - Street 1:300 TOWER RD NE
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9404
Practice Address - Country:US
Practice Address - Phone:770-499-9918
Practice Address - Fax:770-792-8276
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0084342251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52198163006OtherBCBS AUSTELL LOCATION
GA52198163002OtherBCBS MARIETTA LOCATION
GA52198163004OtherBCBS WOODSTOCK LOCATION
GA52198163008OtherBCBS DOUGLASVILLE LOCATIO
GA52198163008OtherBCBS DOUGLASVILLE LOCATIO
GAQ53810Medicare UPIN