Provider Demographics
NPI:1255536702
Name:CONNELL, VICKI MARIE (AUD)
Entity type:Individual
Prefix:MS
First Name:VICKI
Middle Name:MARIE
Last Name:CONNELL
Suffix:
Gender:F
Credentials:AUD
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 12868
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-2868
Mailing Address - Country:US
Mailing Address - Phone:727-532-1355
Mailing Address - Fax:727-266-4928
Practice Address - Street 1:620 10TH STREET N.
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1407
Practice Address - Country:US
Practice Address - Phone:727-824-7170
Practice Address - Fax:727-824-7142
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY 744231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004338301Medicaid
FLS2009WMedicare PIN