Provider Demographics
NPI:1447001193
Name:STEPHENSON, CONNOR
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 RUTLEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5349
Mailing Address - Country:US
Mailing Address - Phone:864-704-2837
Mailing Address - Fax:
Practice Address - Street 1:101 MANNING DR RM 1017
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-4226
Practice Address - Country:US
Practice Address - Phone:984-974-1072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRTL24-0669390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program