Basic Information
| Provider Information | |||||||||
| NPI: | 1184614059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCONNELL | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6031 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452706031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135574270 | ||||||||
| FaxNumber: | 5135573214 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 SOUTH LOOP RD | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593015600 | ||||||||
| FaxNumber: | 8593015669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 002082 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 87001582 | 05 | KY | MEDICAID |