Provider Demographics
NPI:1699105262
Name:CONNER, LAURA GRAY (MS, RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:GRAY
Last Name:CONNER
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 RASPBERRY RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:TN
Mailing Address - Zip Code:38260-5268
Mailing Address - Country:US
Mailing Address - Phone:731-446-8828
Mailing Address - Fax:
Practice Address - Street 1:400 E TICKLE ST
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3120
Practice Address - Country:US
Practice Address - Phone:731-287-2469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000001955133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered