Provider Demographics
NPI:1063849669
Name:KONWENT, NAKIA DAISY (PTA)
Entity Type:Individual
Prefix:MRS
First Name:NAKIA
Middle Name:DAISY
Last Name:KONWENT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 16TH ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4467
Mailing Address - Country:US
Mailing Address - Phone:262-898-2777
Mailing Address - Fax:
Practice Address - Street 1:6101 16TH ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-4467
Practice Address - Country:US
Practice Address - Phone:262-898-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-27
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1869-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant