Provider Demographics
NPI:1487250072
Name:CONWELL, ISHMAEL
Entity type:Individual
Prefix:
First Name:ISHMAEL
Middle Name:
Last Name:CONWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8948 PERSIMMON TRL APT 304
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-4029
Mailing Address - Country:US
Mailing Address - Phone:843-997-4145
Mailing Address - Fax:
Practice Address - Street 1:8948 PERSIMMON TRL APT 304
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-4029
Practice Address - Country:US
Practice Address - Phone:843-997-4145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000013148225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist