Provider Demographics
NPI:1194435685
Name:CONN, AMBER
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:CONN
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 1:38326 PLAINVIEW DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-1437
Mailing Address - Country:US
Mailing Address - Phone:586-845-8265
Mailing Address - Fax:
Practice Address - Street 1:38326 PLAINVIEW DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-1437
Practice Address - Country:US
Practice Address - Phone:586-845-8265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-25
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103TC2200X156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1223343236Medicaid