Provider Demographics
NPI:1255082608
Name:CONNOR, LILLIAN ROSE (PTA)
Entity type:Individual
Prefix:MS
First Name:LILLIAN
Middle Name:ROSE
Last Name:CONNOR
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-0779
Mailing Address - Country:US
Mailing Address - Phone:907-399-3686
Mailing Address - Fax:
Practice Address - Street 1:601 E PIONEER AVE STE 218
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7694
Practice Address - Country:US
Practice Address - Phone:907-235-7473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-17
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK186254225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant