Provider Demographics
NPI:1194009100
Name:CONSTANT, WISMICK
Entity Type:Individual
Prefix:
First Name:WISMICK
Middle Name:
Last Name:CONSTANT
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 1:49 ELSTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3911
Mailing Address - Country:US
Mailing Address - Phone:973-767-6953
Mailing Address - Fax:
Practice Address - Street 1:49 ELSTON ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3911
Practice Address - Country:US
Practice Address - Phone:973-767-6953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304491164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse