Provider Demographics
NPI:1962806687
Name:CONNELL, KATHLIN JEAN
Entity type:Individual
Prefix:
First Name:KATHLIN
Middle Name:JEAN
Last Name:CONNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4114
Mailing Address - Country:US
Mailing Address - Phone:970-631-3687
Mailing Address - Fax:
Practice Address - Street 1:1304 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4114
Practice Address - Country:US
Practice Address - Phone:970-631-3687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0016744225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist