Provider Demographics
NPI:1730487299
Name:CONDECIDO, FORTUNATA S (FNP-BC)
Entity Type:Individual
Prefix:
First Name:FORTUNATA
Middle Name:S
Last Name:CONDECIDO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 W ATLANTIC ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-1906
Mailing Address - Country:US
Mailing Address - Phone:434-584-2000
Mailing Address - Fax:434-447-2240
Practice Address - Street 1:514 W ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-1906
Practice Address - Country:US
Practice Address - Phone:434-584-2000
Practice Address - Fax:434-447-2240
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169248363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1730487299Medicaid
VA1730487299OtherNPI
VA540551711OtherEMPLOYER
VA542019967OtherEMPLOYER
VA1730487299OtherNPI