Provider Demographics
NPI:1154395549
Name:JAKUBISIN-KONICKI, ANNETTE (NP)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:JAKUBISIN-KONICKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 POMFRET ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1836
Mailing Address - Country:US
Mailing Address - Phone:860-963-6390
Mailing Address - Fax:860-963-6343
Practice Address - Street 1:320 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1836
Practice Address - Country:US
Practice Address - Phone:860-963-6390
Practice Address - Fax:860-963-6343
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTR38193363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT500HBE168CT01OtherBLUECROSS BLUESHIELD
P40896Medicare UPIN