Provider Demographics
NPI:1134249055
Name:CONDEFER, KELLY A (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:CONDEFER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2028
Mailing Address - Country:US
Mailing Address - Phone:509-663-8711
Mailing Address - Fax:509-665-5890
Practice Address - Street 1:820 N CHELAN AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2028
Practice Address - Country:US
Practice Address - Phone:509-663-8711
Practice Address - Fax:509-665-5890
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2308862084N0400X
WAMD602095862084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0280068OtherL&I
WA2012612Medicaid
WAG8900760Medicare PIN
WA2012612Medicaid