Provider Demographics
NPI:1336650746
Name:CONNER, ANITA (RD, LD)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:CONNER
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 SHADOW LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-6204
Mailing Address - Country:US
Mailing Address - Phone:770-603-3978
Mailing Address - Fax:
Practice Address - Street 1:2470 MOUNT ZION PKWY
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2500
Practice Address - Country:US
Practice Address - Phone:770-603-3978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
GALD001889133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No174H00000XOther Service ProvidersHealth Educator