Healthcare Provider Details

I. General information

NPI: 1508268947
Provider Name (Legal Business Name): KATHERINE KONCHALSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PATEWOOD DR STE A200
GREENVILLE SC
29615-3580
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-454-5115
  • Fax: 864-454-5111
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number19064
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: