Provider Demographics
NPI:1487266904
Name:CONNELLY, AMANDA MAY (LMT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MAY
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ECK CIR STE 1
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-3865
Mailing Address - Country:US
Mailing Address - Phone:570-322-1245
Mailing Address - Fax:570-322-2564
Practice Address - Street 1:100 ECK CIR STE 1
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3865
Practice Address - Country:US
Practice Address - Phone:570-322-1245
Practice Address - Fax:570-322-2564
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG011416225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist