Provider Demographics
NPI:1265899421
Name:CONDREN, AGNES
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:CONDREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10020 N RODNEY PARHAM RD
Mailing Address - Street 2:STE F
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72227-5588
Mailing Address - Country:US
Mailing Address - Phone:501-779-8327
Mailing Address - Fax:
Practice Address - Street 1:10020 N RODNEY PARHAM RD
Practice Address - Street 2:STE F
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72227-5588
Practice Address - Country:US
Practice Address - Phone:501-779-8327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-19
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1304133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered