Provider Demographics
NPI:1851780878
Name:ESTIME- CONNELLY, ESTERCIO
Entity Type:Individual
Prefix:MRS
First Name:ESTERCIO
Middle Name:
Last Name:ESTIME- CONNELLY
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 1:5150 NW MILNER DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3392
Mailing Address - Country:US
Mailing Address - Phone:772-462-3800
Mailing Address - Fax:
Practice Address - Street 1:714 AVENUE C
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4189
Practice Address - Country:US
Practice Address - Phone:772-462-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0079327700Medicaid