Provider Demographics
NPI:1891141321
Name:KONOPKA, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KONOPKA
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 1:13200 VILLAGE GREEN DR
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-8039
Mailing Address - Country:US
Mailing Address - Phone:847-961-5635
Mailing Address - Fax:
Practice Address - Street 1:13200 VILLAGE GREEN DR
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-8039
Practice Address - Country:US
Practice Address - Phone:847-961-5635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.288885183500000X
IN26020189A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist