1659701761 NPI number — DR. MARISA NICOLE KONEFAL PHARM.D.

Table of content: DR. MARISA NICOLE KONEFAL PHARM.D. (NPI 1659701761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659701761 NPI number — DR. MARISA NICOLE KONEFAL PHARM.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KONEFAL
Provider First Name:
MARISA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659701761
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4014 CORNWALL CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95677-3247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-606-5167
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 BROADWAY ST # L011102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDWOOD CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94063-3132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-724-6076
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/26/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  RPH71162 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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