Provider Demographics
NPI:1235988684
Name:CONDE, MATENNE
Entity type:Individual
Prefix:
First Name:MATENNE
Middle Name:
Last Name:CONDE
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 1:2622 S SHIELDS ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19142-2714
Mailing Address - Country:US
Mailing Address - Phone:267-777-1360
Mailing Address - Fax:
Practice Address - Street 1:2622 S SHIELDS ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19142-2714
Practice Address - Country:US
Practice Address - Phone:267-777-1360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA77193601374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide