Basic Information
| Provider Information | |||||||||
| NPI: | 1740525054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNER | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | BECK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CPNP-PC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BECK | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | CHRISTINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705357745 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | BALDWIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305114000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067762368 | ||||||||
| FaxNumber: | 7067762589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2012 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | RN194985 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 003129979C | 05 | GA | MEDICAID | 003129979D | 05 | GA | MEDICAID | 003129979B | 05 | GA | MEDICAID | 003129979A | 05 | GA | MEDICAID | 003129979E | 05 | GA | MEDICAID |