Provider Demographics
NPI:1639300189
Name:BONE, CONSTANCE FAYE (RD, LD, CNSD)
Entity Type:Individual
Prefix:MS
First Name:CONSTANCE
Middle Name:FAYE
Last Name:BONE
Suffix:
Gender:F
Credentials:RD, LD, CNSD
Other - Prefix:MS
Other - First Name:CONNIE
Other - Middle Name:FAYE
Other - Last Name:BONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD, LD, CNSD
Mailing Address - Street 1:10320 OLD 81 LOOP
Mailing Address - Street 2:
Mailing Address - City:RUDY
Mailing Address - State:AR
Mailing Address - Zip Code:72952-9776
Mailing Address - Country:US
Mailing Address - Phone:479-410-2453
Mailing Address - Fax:
Practice Address - Street 1:1001 TOWSON AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4921
Practice Address - Country:US
Practice Address - Phone:479-441-5289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR492133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered