Provider Demographics
NPI:1023347739
Name:PACKER, CONNIE L (MS, RD, CD)
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:L
Last Name:PACKER
Suffix:
Gender:F
Credentials:MS, RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 S 1230 W
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-5531
Mailing Address - Country:US
Mailing Address - Phone:801-857-7440
Mailing Address - Fax:866-340-7791
Practice Address - Street 1:910 E 100 N
Practice Address - Street 2:SUITE 105
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1635
Practice Address - Country:US
Practice Address - Phone:801-857-7440
Practice Address - Fax:866-340-7791
Is Sole Proprietor?:No
Enumeration Date:2009-12-09
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6324049-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered