Provider Demographics
NPI:1790386340
Name:CONNER, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CONNER
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 1:19265 JEB STUART HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:VA
Mailing Address - Zip Code:24171-4458
Mailing Address - Country:US
Mailing Address - Phone:276-694-2780
Mailing Address - Fax:
Practice Address - Street 1:19265 JEB STUART HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:VA
Practice Address - Zip Code:24171-4458
Practice Address - Country:US
Practice Address - Phone:276-694-2780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202209343183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist