Provider Demographics
NPI:1841807435
Name:CONYERS, THERESA LYNN
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:CONYERS
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 1:3701 WALES DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-1848
Mailing Address - Country:US
Mailing Address - Phone:937-620-4321
Mailing Address - Fax:
Practice Address - Street 1:3701 WALES DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-1848
Practice Address - Country:US
Practice Address - Phone:937-620-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRR627109171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor