Provider Demographics
NPI:1639660152
Name:CONKLIN, MEGHAN
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:CONKLIN
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 1:408 CAMBIASO PL
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-3619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:341 IRWIN LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5603
Practice Address - Country:US
Practice Address - Phone:707-576-7218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$Medicaid