Provider Demographics
NPI:1043437817
Name:CONGER, LORI MICHELLE (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:MICHELLE
Last Name:CONGER
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:
Other - Last Name:WALLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:42450-0037
Mailing Address - Country:US
Mailing Address - Phone:270-667-7017
Mailing Address - Fax:
Practice Address - Street 1:215 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:KY
Practice Address - Zip Code:42450-1261
Practice Address - Country:US
Practice Address - Phone:270-667-7017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-05-1869133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0281305Medicare ID - Type UnspecifiedLYON CO
KY0290805Medicare ID - Type UnspecifiedTRIGG CO
KY0050406Medicare ID - Type UnspecifiedCALDWELL CO
KY0291005Medicare ID - Type UnspecifiedLIVINGSTON CO
KY0290902Medicare ID - Type UnspecifiedCRITTENDEN CO