Provider Demographics
NPI:1104405133
Name:CONNELL, ERICA (LPTA)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:CONNELL
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2034 SUNSET PINE WAY
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-9774
Mailing Address - Country:US
Mailing Address - Phone:205-585-7654
Mailing Address - Fax:
Practice Address - Street 1:30 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1158
Practice Address - Country:US
Practice Address - Phone:850-651-2635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28370208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation