Provider Demographics
NPI:1255075891
Name:KONOPACKE, MEGAN E
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:E
Last Name:KONOPACKE
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 1:175 E 100 N # B
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4601
Mailing Address - Country:US
Mailing Address - Phone:435-755-0439
Mailing Address - Fax:
Practice Address - Street 1:8530 S 500 W
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:UT
Practice Address - Zip Code:84328-7701
Practice Address - Country:US
Practice Address - Phone:435-938-6125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12769250-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily