Provider Demographics
NPI:1720865678
Name:KONNEY, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:KONNEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 TRELIPE DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-2341
Mailing Address - Country:US
Mailing Address - Phone:254-245-3633
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA #2,KM,80.4
Practice Address - Street 2:BARRIO SAN DANIEL
Practice Address - City:SECTOR LAS CANELAS,ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00614-4050
Practice Address - Country:US
Practice Address - Phone:787-878-5475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11032724367500000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered