Provider Demographics
NPI:1043593924
Name:CONDERINO, MICHELE LEE (BA)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LEE
Last Name:CONDERINO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 EAST AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-5703
Mailing Address - Country:US
Mailing Address - Phone:203-750-9711
Mailing Address - Fax:203-750-9651
Practice Address - Street 1:120 EAST AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-5703
Practice Address - Country:US
Practice Address - Phone:203-750-9711
Practice Address - Fax:203-750-9651
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008003511Medicaid