Healthcare Provider Details

I. General information

NPI: 1336650746
Provider Name (Legal Business Name): ANITA CONNER RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 10/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2470 MOUNT ZION PKWY
JONESBORO GA
30236-2500
US

IV. Provider business mailing address

712 SHADOW LAKE DR
LITHONIA GA
30058-6204
US

V. Phone/Fax

Practice location:
  • Phone: 770-603-3978
  • Fax:
Mailing address:
  • Phone: 770-603-3978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberLD001889
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: