Provider Demographics
NPI:1417160664
Name:KONDRATH, CAROL H (APNP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:H
Last Name:KONDRATH
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 EAST FIRST STREET
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805
Mailing Address - Country:US
Mailing Address - Phone:218-728-4404
Mailing Address - Fax:218-728-4404
Practice Address - Street 1:1500 N 34TH ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-4477
Practice Address - Country:US
Practice Address - Phone:218-730-2351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1900003163W00000X, 163WP0808X
WI1900-033363LP0808X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0007-84267OtherREGULAR MEDICARE
WI40945600Medicaid