Provider Demographics
NPI:1902435746
Name:MCCONIE, COLLEEN KELLY (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:KELLY
Last Name:MCCONIE
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CROSS LN
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11709-3101
Mailing Address - Country:US
Mailing Address - Phone:516-729-1435
Mailing Address - Fax:
Practice Address - Street 1:5 CROSS LN
Practice Address - Street 2:
Practice Address - City:BAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11709-3101
Practice Address - Country:US
Practice Address - Phone:516-729-1435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003802-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer