Basic Information
| Provider Information | |||||||||
| NPI: | 1639487572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNERLEY | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BARCLAY | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 83 AIRWAYS PL | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386715885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623498787 | ||||||||
| FaxNumber: | 6623498757 | ||||||||
| Practice Location | |||||||||
| Address1: | 83 AIRWAYS PL | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386715885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623498787 | ||||||||
| FaxNumber: | 6623498757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2010 | ||||||||
| LastUpdateDate: | 09/14/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT4810 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.