Healthcare Provider Details

I. General information

NPI: 1598179640
Provider Name (Legal Business Name): ANDREW KONESKY APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 VAUXHALL ST
NEW LONDON CT
06320-5711
US

IV. Provider business mailing address

255 HEMPSTEAD ST
NEW LONDON CT
06320-6204
US

V. Phone/Fax

Practice location:
  • Phone: 860-442-2797
  • Fax: 860-701-3776
Mailing address:
  • Phone: 860-443-2896
  • Fax: 860-442-5909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5806
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number107198
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: