Provider Demographics
NPI:1124086525
Name:PHILLIPS, CONNIE ELLIS (PT)
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:ELLIS
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 PREMIER DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6076
Mailing Address - Country:US
Mailing Address - Phone:507-386-6600
Mailing Address - Fax:507-625-5971
Practice Address - Street 1:1431 PREMIER DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6076
Practice Address - Country:US
Practice Address - Phone:507-386-6670
Practice Address - Fax:507-388-8372
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5346225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN103183C572OtherUCARE MN
MN448T1PHOtherBCBS OF MN
MNHP42303OtherHEALTH PARTNERS
MN983181027668OtherPREFERRED ONE
MN6404803OtherMEDICA
MNH033OtherTRICARE