Provider Demographics
NPI:1972682276
Name:CONNER, CONNIE SUE (RD)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:SUE
Last Name:CONNER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 S 950 W
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46012-9324
Mailing Address - Country:US
Mailing Address - Phone:765-759-8657
Mailing Address - Fax:
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:765-741-1802
Practice Address - Fax:765-741-2994
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN296500EEMedicare ID - Type UnspecifiedUPLAND HEALTH & DIAG
IN9408100Medicare Oscar/Certification