Provider Demographics
NPI:1922010784
Name:CONDIT, MOLLY T (CRNA)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:T
Last Name:CONDIT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:T
Other - Last Name:HENNIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2845 GREENBRIER RD
Mailing Address - Street 2:PO BOX 8900
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54308-8900
Mailing Address - Country:US
Mailing Address - Phone:920-288-3388
Mailing Address - Fax:920-288-3370
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-3388
Practice Address - Fax:920-288-3370
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2021-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI138939367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44345400Medicaid
WI44345400Medicaid
Q09422Medicare UPIN