Provider Demographics
NPI:1780942268
Name:CONNELL, MICHELLE RENE (DOM)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:RENE
Last Name:CONNELL
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1395 N COURTENAY PKWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4400
Mailing Address - Country:US
Mailing Address - Phone:407-864-6465
Mailing Address - Fax:321-252-3752
Practice Address - Street 1:1395 N COURTENAY PKWY
Practice Address - Street 2:SUITE 202
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4400
Practice Address - Country:US
Practice Address - Phone:407-864-6465
Practice Address - Fax:321-252-3752
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLAP 3097171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist