Provider Demographics
NPI:1588741938
Name:KONETZKO, KATHLEEN (NP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:KONETZKO
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 1:2305 MINNESOTA BLVD
Mailing Address - Street 2:MINN CORRECTIONAL FACILITY
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56304-2424
Mailing Address - Country:US
Mailing Address - Phone:320-240-3088
Mailing Address - Fax:320-240-7087
Practice Address - Street 1:2305 MINNESOTA BLVD
Practice Address - Street 2:MINN CORRECTIONAL FACILITY
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56304-2424
Practice Address - Country:US
Practice Address - Phone:320-240-3088
Practice Address - Fax:320-240-7087
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 070073-7363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily