Provider Demographics
NPI:1134798663
Name:FULLWOOD, CONSTANCE (PHNL, PMHNP-BC)
Entity type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:
Last Name:FULLWOOD
Suffix:
Gender:F
Credentials:PHNL, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MADISON AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-1600
Mailing Address - Country:US
Mailing Address - Phone:212-545-2400
Mailing Address - Fax:212-463-8411
Practice Address - Street 1:36-11 21ST ST
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11106-4505
Practice Address - Country:US
Practice Address - Phone:718-482-7772
Practice Address - Fax:718-482-9648
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-19
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN250856363LP0808X
NYF405449-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health