Provider Demographics
NPI:1538467469
Name:ANDERSEN, CONSTANCE
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 W SIX CLAIMS RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7033
Mailing Address - Country:US
Mailing Address - Phone:928-541-7649
Mailing Address - Fax:
Practice Address - Street 1:440 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2642
Practice Address - Country:US
Practice Address - Phone:928-443-1991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ900044174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist