Provider Demographics
NPI:1235638065
Name:KONCILJA, LANIE M (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LANIE
Middle Name:M
Last Name:KONCILJA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 ARCH ST STE 1B
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44304-1436
Mailing Address - Country:US
Mailing Address - Phone:330-375-3315
Mailing Address - Fax:
Practice Address - Street 1:55 ARCH ST STE 1B
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1436
Practice Address - Country:US
Practice Address - Phone:330-375-3315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.023865207R00000X
OHF10170157207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94-3069757OtherPPO