Provider Demographics
NPI:1992912331
Name:KONSHUK, KETARAE ANN (LMP)
Entity type:Individual
Prefix:
First Name:KETARAE
Middle Name:ANN
Last Name:KONSHUK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 WEST HAZEL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273
Mailing Address - Country:US
Mailing Address - Phone:360-610-1693
Mailing Address - Fax:
Practice Address - Street 1:619 W HAZEL ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4827
Practice Address - Country:US
Practice Address - Phone:360-610-1693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA-19764174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist