Provider Demographics
NPI:1770567620
Name:OCONNELL, PATRICIA (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:OCONNELL
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:
Other - Last Name:LODGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:56 WATER ST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-2887
Mailing Address - Country:US
Mailing Address - Phone:727-364-4024
Mailing Address - Fax:
Practice Address - Street 1:56 WATER ST
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-2887
Practice Address - Country:US
Practice Address - Phone:727-364-4024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT38010225100000X
CA24904225100000X
OR4955225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269792Medicaid