Basic Information
| Provider Information | |||||||||
| NPI: | 1417160664 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KONDRATH | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 EAST FIRST STREET | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187284404 | ||||||||
| FaxNumber: | 2187284404 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 N 34TH ST | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548804477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187302351 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 05/23/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 1900003 | WI | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 1900-033 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 364S00000X | 1900-033 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 163WP0808X | 1900003 | WI | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0007-84267 | 01 | WI | REGULAR MEDICARE | OTHER | 40945600 | 05 | WI | MEDICAID |