Basic Information
| Provider Information | |||||||||
| NPI: | 1336650746 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONNER | ||||||||
| FirstName: | ANITA | ||||||||
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| Credential: | RD, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 SHADOW LAKE DR | ||||||||
| Address2: | |||||||||
| City: | LITHONIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300586204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706033978 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2470 MOUNT ZION PKWY | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302362500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706033978 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2017 | ||||||||
| LastUpdateDate: | 10/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174H00000X | N | Other Service Providers | Health Educator | 133VN1005X | LD001889 | GA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Renal |
No ID Information.