Provider Demographics
NPI:1154917854
Name:CONNER, KELLY JEANETTE (LAC, LMBT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEANETTE
Last Name:CONNER
Suffix:
Gender:F
Credentials:LAC, LMBT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEANETTE
Other - Last Name:CONNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC, LMBT
Mailing Address - Street 1:7116C SIX FORKS RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-6157
Mailing Address - Country:US
Mailing Address - Phone:919-891-9991
Mailing Address - Fax:919-847-3148
Practice Address - Street 1:7116C SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6157
Practice Address - Country:US
Practice Address - Phone:919-891-9991
Practice Address - Fax:919-847-3148
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC709171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty