Provider Demographics
NPI:1679619944
Name:FALLSTROM, CONSTANCE ANNA (PT)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:ANNA
Last Name:FALLSTROM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 CASTLEVALE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-7800
Mailing Address - Country:US
Mailing Address - Phone:509-457-0202
Mailing Address - Fax:509-457-0404
Practice Address - Street 1:3909 CASTLEVALE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-7800
Practice Address - Country:US
Practice Address - Phone:509-457-0202
Practice Address - Fax:509-457-0404
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025208PT00005978225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8347692Medicaid
WAP28602Medicare UPIN
WAAB20933Medicare ID - Type Unspecified