Healthcare Provider Details

I. General information

NPI: 1083802193
Provider Name (Legal Business Name): MELINDA KONRATH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 S OLIVE ST SUITE E
SOUTH BEND IN
46619-2100
US

IV. Provider business mailing address

244 S OLIVE ST SUITE E
SOUTH BEND IN
46619-2100
US

V. Phone/Fax

Practice location:
  • Phone: 574-282-3230
  • Fax: 574-282-3240
Mailing address:
  • Phone: 574-282-3230
  • Fax: 574-282-3240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number28140334A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: