MEDICARE: KATIE MARIE KONECKE

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	363LX0001X	Obstetrics & Gynecology Nurse Practitioner	209.030171	IL
2	163W00000X	Registered Nurse	4704316399	MI
3	163W00000X	Registered Nurse	041.517979	IL

General Provider Information

NPI Number	:	1790517324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATIE MARIE KONECKE

Provider Business Mailing Address
First Line	:	415 PERSIMMON LN
Second Line	:
City	:	BARTLETT
State	:	IL
Zip	:	60103-1583
Country	:	US
Telephone Number	:	630-973-8138
Fax Number	:

Provider Business Practice Location Address
First Line	:	1555 N BARRINGTON RD STE 425
Second Line	:
City	:	HOFFMAN ESTATES
State	:	IL
Zip	:	60169-1065
Country	:	US
Telephone Number	:	847-755-1111
Fax Number	:

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

Provider Enumeration Date	:	08/14/2024
Last Update Date	:	08/14/2024

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