MEDICARE: REBECCA KONKIN NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	71001535A	IN

General Provider Information

NPI Number	:	1053376186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA KONKIN NP

Provider Business Mailing Address
First Line	:	2700 LAFAYETTE ST
Second Line	:	STE B-10
City	:	FORT WAYNE
State	:	IN
Zip	:	46806-1100
Country	:	US
Telephone Number	:	260-744-7004
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 LAFAYETTE ST
Second Line	:	STE B-10
City	:	FORT WAYNE
State	:	IN
Zip	:	46806-1100
Country	:	US
Telephone Number	:	260-744-7004
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	10/30/2007

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