Provider Demographics
NPI:1063176063
Name:CONNER, IMANI KRYSTINE (ACT)
Entity type:Individual
Prefix:
First Name:IMANI
Middle Name:KRYSTINE
Last Name:CONNER
Suffix:
Gender:F
Credentials:ACT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 SUNSET DOWN CT
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7925
Mailing Address - Country:US
Mailing Address - Phone:678-886-4386
Mailing Address - Fax:
Practice Address - Street 1:3400 S FIGUEROA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0002
Practice Address - Country:US
Practice Address - Phone:213-740-0626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer