Provider Demographics
NPI:1700924586
Name:KONNICK, DAVID E JR (LPN)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:E
Last Name:KONNICK
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 ROBIN RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-8941
Mailing Address - Country:US
Mailing Address - Phone:631-849-5115
Mailing Address - Fax:
Practice Address - Street 1:320 BLUEPOINT RD.
Practice Address - Street 2:
Practice Address - City:BLUEPOINT
Practice Address - State:NY
Practice Address - Zip Code:11715
Practice Address - Country:US
Practice Address - Phone:631-357-1050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280386164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02668197Medicaid