Provider Demographics
NPI:1316494040
Name:CONNER, NICOLE (MS)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:CONNER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 MCMILLAN LN
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-1336
Mailing Address - Country:US
Mailing Address - Phone:815-814-0031
Mailing Address - Fax:
Practice Address - Street 1:4910 MCMILLAN LN
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-1336
Practice Address - Country:US
Practice Address - Phone:815-814-0031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-11
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242003944235Z00000X
IL146013777235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist