Provider Demographics
NPI:1366418998
Name:GONDRAN, SUE ELLEN (FNP)
Entity type:Individual
Prefix:MRS
First Name:SUE
Middle Name:ELLEN
Last Name:GONDRAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MISS
Other - First Name:SUE
Other - Middle Name:ELLEN
Other - Last Name:JOHANSSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6406 N IH 35
Mailing Address - Street 2:STE 2600
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752-4352
Mailing Address - Country:US
Mailing Address - Phone:512-465-4800
Mailing Address - Fax:512-420-0118
Practice Address - Street 1:6406 N IH 35
Practice Address - Street 2:STE 2600
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-4352
Practice Address - Country:US
Practice Address - Phone:512-465-4800
Practice Address - Fax:512-420-0118
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP106545363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB153125OtherWELLMED PTAN
TX092886304Medicaid
TXTXB153125OtherWELLMED PTAN