Provider Demographics
NPI:1255517439
Name:CONROY, JOANNA SULLIVAN
Entity type:Individual
Prefix:MS
First Name:JOANNA
Middle Name:SULLIVAN
Last Name:CONROY
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 1:7310 RITCHIE HWY
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3065
Mailing Address - Country:US
Mailing Address - Phone:410-788-6727
Mailing Address - Fax:410-788-6729
Practice Address - Street 1:7310 RITCHIE HWY STE 405
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061
Practice Address - Country:US
Practice Address - Phone:410-788-6727
Practice Address - Fax:410-788-6729
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD02222133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD800142944Medicaid