Provider Demographics
NPI:1538374129
Name:CONDELLO, VIVIAN L (RN, MS, FNP, IBCLC)
Entity type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:L
Last Name:CONDELLO
Suffix:
Gender:F
Credentials:RN, MS, FNP, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 CLOONEY DR
Mailing Address - Street 2:
Mailing Address - City:HENRIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:14467-8902
Mailing Address - Country:US
Mailing Address - Phone:585-334-4049
Mailing Address - Fax:
Practice Address - Street 1:350 NEW CAMPUS DR
Practice Address - Street 2:HAZEN HALL
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-2997
Practice Address - Country:US
Practice Address - Phone:585-395-2414
Practice Address - Fax:585-395-2559
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252168-1163WL0100X
NYF332995-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB7031OtherMEDICARE PTAN