Provider Demographics
NPI:1790208148
Name:KONAN, NIKO (LPN)
Entity Type:Individual
Prefix:
First Name:NIKO
Middle Name:
Last Name:KONAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1588
Mailing Address - Street 2:
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590-8588
Mailing Address - Country:US
Mailing Address - Phone:845-309-3435
Mailing Address - Fax:845-231-0508
Practice Address - Street 1:4 MARSHALL RD STE 248
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-4105
Practice Address - Country:US
Practice Address - Phone:845-309-3435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY328280164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty