Provider Demographics
NPI:1346137395
Name:CONNOR, DERRICK
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:CONNOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 21ST AVE N
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075-1504
Mailing Address - Country:US
Mailing Address - Phone:507-573-3550
Mailing Address - Fax:
Practice Address - Street 1:632 21ST AVE N
Practice Address - Street 2:
Practice Address - City:SOUTH SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55075-1504
Practice Address - Country:US
Practice Address - Phone:507-573-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN86289524133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered