Healthcare Provider Details

I. General information

NPI: 1235844424
Provider Name (Legal Business Name): MICHAEL CONNOR SELF NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 CHURCH ST NE
MARIETTA GA
30060-1101
US

IV. Provider business mailing address

677 CHURCH ST NE STE 100
MARIETTA GA
30060-1101
US

V. Phone/Fax

Practice location:
  • Phone: 770-793-5000
  • Fax:
Mailing address:
  • Phone: 770-422-2326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number29347
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberRN313506
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: