Provider Demographics
NPI:1215601869
Name:KONWALSKI, FLORENCE MARIE
Entity Type:Individual
Prefix:
First Name:FLORENCE
Middle Name:MARIE
Last Name:KONWALSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 GRAPEVINE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:WV
Mailing Address - Zip Code:26033-1225
Mailing Address - Country:US
Mailing Address - Phone:304-280-0055
Mailing Address - Fax:
Practice Address - Street 1:925 GRAPEVINE RIDGE DR
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:WV
Practice Address - Zip Code:26033-1225
Practice Address - Country:US
Practice Address - Phone:304-280-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1821206228Medicaid
WY1255523494Medicaid
WV1356607394Medicaid