Provider Demographics
NPI:1033302963
Name:SHEA, CONNIE MARTHA (LMT)
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:MARTHA
Last Name:SHEA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2704 NE 25TH ST
Mailing Address - Street 2:OCALA MSI CENTER FOR PAIN RELIEF LLC
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34470-3985
Mailing Address - Country:US
Mailing Address - Phone:352-209-3054
Mailing Address - Fax:352-291-5004
Practice Address - Street 1:2704 NE 25TH ST
Practice Address - Street 2:OCALA MSI CENTER FOR PAIN RELIEF LLC
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-3985
Practice Address - Country:US
Practice Address - Phone:352-209-3054
Practice Address - Fax:352-291-5004
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA16262225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC8971OtherBLUE CROSS BLUE SHIELD