Provider Demographics
NPI:1043940737
Name:CONNOR, MACKENZIE LYNN (HIS)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LYNN
Last Name:CONNOR
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:LYNN
Other - Last Name:DINATALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:HIS
Mailing Address - Street 1:101 YORKTOWN DR STE 201
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1501
Mailing Address - Country:US
Mailing Address - Phone:770-461-0043
Mailing Address - Fax:
Practice Address - Street 1:101 YORKTOWN DR STE 201
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1501
Practice Address - Country:US
Practice Address - Phone:770-461-0043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAHADS001077237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist