Provider Demographics
NPI:1477505535
Name:KONZELMAN, RITA T (CRNP)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:T
Last Name:KONZELMAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 CONCHESTER HWY
Mailing Address - Street 2:STE 5A
Mailing Address - City:GARNET VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19060-2105
Mailing Address - Country:US
Mailing Address - Phone:856-231-4774
Mailing Address - Fax:
Practice Address - Street 1:3001 E EVESHAM RD
Practice Address - Street 2:ON-SITE SPECIALTY CARE- CRNP
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9547
Practice Address - Country:US
Practice Address - Phone:856-751-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP003516C363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0092835Medicaid
PA101061845Medicaid
NJ0092835Medicaid
PA101061845Medicaid
PA045383Medicare ID - Type Unspecified