Provider Demographics
NPI:1659734259
Name:CONGDON, MARANDA (LPN)
Entity Type:Individual
Prefix:
First Name:MARANDA
Middle Name:
Last Name:CONGDON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:31314
Practice Address - Country:US
Practice Address - Phone:706-436-0712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX330656164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse