MEDICARE: KATHLEEN KONETZKO NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R 070073-7	MN

General Provider Information

NPI Number	:	1588741938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN KONETZKO NP

Provider Business Mailing Address
First Line	:	2305 MINNESOTA BLVD
Second Line	:	MINN CORRECTIONAL FACILITY
City	:	SAINT CLOUD
State	:	MN
Zip	:	56304-2424
Country	:	US
Telephone Number	:	320-240-3088
Fax Number	:	320-240-7087

Provider Business Practice Location Address
First Line	:	2305 MINNESOTA BLVD
Second Line	:	MINN CORRECTIONAL FACILITY
City	:	SAINT CLOUD
State	:	MN
Zip	:	56304-2424
Country	:	US
Telephone Number	:	320-240-3088
Fax Number	:	320-240-7087

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/08/2007

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