Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XH1200X | Occupational Therapist - Hand | 5201010040 | MI |
NPI | 1174035828 |
---|---|
Provider Name | Autumn Conner |
First Address | Warren, MI 48088-6675 |
Second Address | Warren, MI 48088-6675 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2017 |
Last Update Date | 16/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5201010040 | STATE LICENSE (01) | MI |