Provider Demographics
NPI:1780747592
Name:STREET, CONSTANCE JEAN (RN)
Entity type:Individual
Prefix:MS
First Name:CONSTANCE
Middle Name:JEAN
Last Name:STREET
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 NE 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-1832
Mailing Address - Country:US
Mailing Address - Phone:541-815-2378
Mailing Address - Fax:
Practice Address - Street 1:1270 KOT-NUM RD
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:OR
Practice Address - Zip Code:97761
Practice Address - Country:US
Practice Address - Phone:541-553-1196
Practice Address - Fax:541-553-1130
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care