Provider Demographics
NPI:1891767125
Name:YOUNG, CONSTANCE L (FNP)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:L
Last Name:YOUNG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 BENHAM ST
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-1205
Mailing Address - Country:US
Mailing Address - Phone:573-358-9119
Mailing Address - Fax:573-358-9489
Practice Address - Street 1:527 BENHAM ST
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-1205
Practice Address - Country:US
Practice Address - Phone:573-358-9119
Practice Address - Fax:573-358-9489
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO076265363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428318000Medicaid
MO428318000Medicaid
MO81532Medicare ID - Type UnspecifiedMEDICARE