Provider Demographics
NPI:1467476440
Name:CONSTANCE, SUSAN (RN)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:CONSTANCE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 269
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0269
Mailing Address - Country:US
Mailing Address - Phone:505-759-1691
Mailing Address - Fax:505-759-7294
Practice Address - Street 1:500 NORTH MUNDO
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528-0269
Practice Address - Country:US
Practice Address - Phone:505-759-3291
Practice Address - Fax:505-759-7294
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO126420163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMHSZ196OtherMEDICARE PART B
NM000K3526Medicaid
NM320057Medicare Oscar/Certification