Provider Demographics
NPI:1376124842
Name:VANVALKENBURG, CONSTANCE ELIZABETH (LPN)
Entity Type:Individual
Prefix:MS
First Name:CONSTANCE
Middle Name:ELIZABETH
Last Name:VANVALKENBURG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 BUNNY TRL
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-6930
Mailing Address - Country:US
Mailing Address - Phone:254-553-8110
Mailing Address - Fax:
Practice Address - Street 1:5200 BUNNY TRL
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-6930
Practice Address - Country:US
Practice Address - Phone:254-553-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171268164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1237410048OtherLPN-164WOOOOOX