Provider Demographics
NPI:1922471473
Name:CONNELLY, LISA A (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2751 2ND AVE N
Mailing Address - Street 2:HYSLOP SPORT CENTER ROOM 144
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58202-6060
Mailing Address - Country:US
Mailing Address - Phone:701-780-2977
Mailing Address - Fax:
Practice Address - Street 1:2751 2ND AVE N
Practice Address - Street 2:HYSLOP SPORT CENTER ROOM 144
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58202-6060
Practice Address - Country:US
Practice Address - Phone:701-780-2977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND690-152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer