Basic Information
| Provider Information | |||||||||
| NPI: | 1063763456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONDON | ||||||||
| FirstName: | EILEEN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 PHOENIX AVE | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067021418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037568021 | ||||||||
| FaxNumber: | 2035969038 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 PHOENIX AVE | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067021418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037568021 | ||||||||
| FaxNumber: | 2035969038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2012 | ||||||||
| LastUpdateDate: | 09/25/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 086024 | CT | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 005100 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.