Provider Demographics
NPI:1295976777
Name:CONDODEMETRAKY, STEPHANIE NICOLE (ARNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:CONDODEMETRAKY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:NICOLE
Other - Last Name:CONDODEMETRAKY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:775 S. MAIN ST.
Mailing Address - Street 2:MANCHESTER MEDICAL GROUP
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-5143
Mailing Address - Country:US
Mailing Address - Phone:603-663-7300
Mailing Address - Fax:603-663-7333
Practice Address - Street 1:775 S. MAIN ST.
Practice Address - Street 2:MANCHESTER MEDICAL GROUP
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-5143
Practice Address - Country:US
Practice Address - Phone:603-663-7300
Practice Address - Fax:603-663-7333
Is Sole Proprietor?:No
Enumeration Date:2009-03-13
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH055471-21163W00000X
NH055471-23363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse