Provider Demographics
NPI:1174086359
Name:CONDOLON-KOHLER, ANNIE ROSE (NP)
Entity type:Individual
Prefix:
First Name:ANNIE ROSE
Middle Name:
Last Name:CONDOLON-KOHLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 ASHTREE CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-3964
Mailing Address - Country:US
Mailing Address - Phone:484-866-0654
Mailing Address - Fax:
Practice Address - Street 1:4520 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-6888
Practice Address - Country:US
Practice Address - Phone:707-646-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-13
Last Update Date:2019-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011293363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily