Provider Demographics
NPI:1952864530
Name:CONDON, KRISTA
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:CONDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1099 JAY ST BLDG P
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14611-1164
Mailing Address - Country:US
Mailing Address - Phone:585-328-0740
Mailing Address - Fax:
Practice Address - Street 1:1099 JAY ST BLDG J
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14611-1153
Practice Address - Country:US
Practice Address - Phone:585-328-0740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist