Provider Demographics
NPI:1417311754
Name:KONZELMANN, IRINA (NP)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:KONZELMANN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 MOUNTAINVIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-3444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:136 MOUNTAINVIEW BLVD
Practice Address - Street 2:
Practice Address - City:BASKING RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07920-3444
Practice Address - Country:US
Practice Address - Phone:908-542-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00622600207RX0202X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology