Provider Demographics
NPI:1700418779
Name:CONLON, MIA CATHERINE KIM
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:CATHERINE KIM
Last Name:CONLON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 SE SOUTHWOOD TRL
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-6369
Mailing Address - Country:US
Mailing Address - Phone:772-485-3089
Mailing Address - Fax:
Practice Address - Street 1:449 SE SOUTHWOOD TRL
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-6369
Practice Address - Country:US
Practice Address - Phone:772-485-3089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer