Provider Demographics
NPI:1720360340
Name:CONDLIN, JENNIFER DAWN (RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:CONDLIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 NORTH COUNTRY ROAD
Mailing Address - Street 2:
Mailing Address - City:PORTJEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:631-473-1320
Mailing Address - Fax:
Practice Address - Street 1:75 NORTH COUNTRY ROAD
Practice Address - Street 2:
Practice Address - City:PORTJEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-473-1320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-10
Last Update Date:2021-05-05
Deactivation Date:2020-11-24
Deactivation Code:
Reactivation Date:2021-04-20
Provider Licenses
StateLicense IDTaxonomies
NY636754-1163W00000X
NYF346007-01363LF0000X
NY346007363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse