Basic Information
| Provider Information | |||||||||
| NPI: | 1851780878 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ESTIME- CONNELLY | ||||||||
| FirstName: | ESTERCIO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5150 NW MILNER DR | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349833392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724623800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 714 AVENUE C | ||||||||
| Address2: | |||||||||
| City: | FORT PIERCE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349504189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724623800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2015 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | FL | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 0079327700 | 05 | FL | MEDICAID |