Healthcare Provider Details

I. General information

NPI: 1558705053
Provider Name (Legal Business Name): CARL KONIECZKA APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2013
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 JENNINGS MILL RD STE 110
WATKINSVILLE GA
30677-7241
US

IV. Provider business mailing address

3875 JAMAICA DR
JONESBORO GA
30236-5428
US

V. Phone/Fax

Practice location:
  • Phone: 706-613-5880
  • Fax:
Mailing address:
  • Phone: 678-935-8049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN210228
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: