Basic Information
Provider Information | |||||||||
NPI: | 1538450986 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CONDE | ||||||||
FirstName: | DAPHNE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ACNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BESTEN | ||||||||
OtherFirstName: | DAPHNE | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 707 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 109402650 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8453337575 | ||||||||
FaxNumber: | 8453337201 | ||||||||
Practice Location | |||||||||
Address1: | 707 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 109402650 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8453337575 | ||||||||
FaxNumber: | 8453337201 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2011 | ||||||||
LastUpdateDate: | 08/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 06/24/2014 | ||||||||
NPIReactivationDate: | 10/02/2014 | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 26NJ00325100 | NJ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | F430616-1 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
ID | Type | State | Issuer | Description | 04062213 | 05 | NY |   | MEDICAID |