Basic Information
| Provider Information | |||||||||
| NPI: | 1760199152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONDE | ||||||||
| FirstName: | DASANI | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 WESTLAKE DR UNIT 3 | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920693705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609175692 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2141 PALOMAR AIRPORT RD STE 350 | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920111451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604380078 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2022 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.