Provider Demographics
NPI:1962488643
Name:CONDRON, LEE ANN (RN, ACNP)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:ANN
Last Name:CONDRON
Suffix:
Gender:F
Credentials:RN, ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 CIMMARRON ST
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-4634
Mailing Address - Country:US
Mailing Address - Phone:936-414-2404
Mailing Address - Fax:936-329-8332
Practice Address - Street 1:1717 HWY 59 S BYPASS
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351
Practice Address - Country:US
Practice Address - Phone:936-329-8326
Practice Address - Fax:936-329-8332
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP112378363L00000X
TX533514363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174262901Medicaid
TX8N8592OtherBLUECROSS AND BLUESHIELD OF TEXAS
TX8N8592OtherBLUECROSS AND BLUESHIELD OF TEXAS
TX8J5194Medicare PIN
TX174262901Medicaid