Provider Demographics
NPI:1447243571
Name:BENTLEY, CONSTANCE S (APRN)
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:S
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:CONNIE
Other - Middle Name:S
Other - Last Name:MARPLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 6605
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-6605
Mailing Address - Country:US
Mailing Address - Phone:903-592-6000
Mailing Address - Fax:903-592-3224
Practice Address - Street 1:2737 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-5413
Practice Address - Country:US
Practice Address - Phone:903-592-6000
Practice Address - Fax:903-592-3224
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP118606363L00000X
TX778072363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0421552Medicaid
IA44628OtherWELLMARK BCBS
IA500024121Medicare PIN
TXI5912Medicare UPIN
P71533Medicare UPIN
IAI5912Medicare PIN