Basic Information
| Provider Information | |||||||||
| NPI: | 1134249055 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONDEFER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 N CHELAN AVE | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988012028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096638711 | ||||||||
| FaxNumber: | 5096655890 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 N CHELAN AVE | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988012028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096638711 | ||||||||
| FaxNumber: | 5096655890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 08/19/2013 | ||||||||
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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 | 2084N0400X | 230886 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | MD60209586 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0280068 | 01 | WA | L&I | OTHER | 2012612 | 05 | WA | MEDICAID |