Provider Demographics
NPI:1124850458
Name:CONNOR, KATHRYN SMITH
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:SMITH
Last Name:CONNOR
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 1:103 W MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2134
Mailing Address - Country:US
Mailing Address - Phone:309-258-1188
Mailing Address - Fax:
Practice Address - Street 1:103 W MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2134
Practice Address - Country:US
Practice Address - Phone:309-258-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051038804183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist