Healthcare Provider Details

I. General information

NPI: 1801374681
Provider Name (Legal Business Name): MARY THORNTON KONKEL ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610
US

IV. Provider business mailing address

PO BOX 100237
GAINESVILLE FL
32610-0237
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-5159
  • Fax: 352-273-5213
Mailing address:
  • Phone: 352-273-5159
  • Fax: 352-273-5213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN9189853
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: