Healthcare Provider Details

I. General information

NPI: 1477203354
Provider Name (Legal Business Name): CONDOLA GARRETT RN IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 03/24/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 ADINA LN NW
ALBUQUERQUE NM
87114-5263
US

IV. Provider business mailing address

9600 ADINA LN NW
ALBUQUERQUE NM
87114-5263
US

V. Phone/Fax

Practice location:
  • Phone: 505-730-7066
  • Fax:
Mailing address:
  • Phone: 505-730-7066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number53043
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: