Healthcare Provider Details

I. General information

NPI: 1790517324
Provider Name (Legal Business Name): KATIE MARIE KONECKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 N BARRINGTON RD STE 425
HOFFMAN ESTATES IL
60169-1065
US

IV. Provider business mailing address

415 PERSIMMON LN
BARTLETT IL
60103-1583
US

V. Phone/Fax

Practice location:
  • Phone: 847-755-1111
  • Fax:
Mailing address:
  • Phone: 630-973-8138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number209.030171
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704316399
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.517979
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: