Healthcare Provider Details

I. General information

NPI: 1861796625
Provider Name (Legal Business Name): CONSTANCE SMYTH THOMAS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2011
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 E SHEA BLVD SUITE 175
PHOENIX AZ
85028-3074
US

IV. Provider business mailing address

1113 W CHURCH ST
CHAMPAIGN IL
61821-2743
US

V. Phone/Fax

Practice location:
  • Phone: 602-464-5251
  • Fax: 480-907-2108
Mailing address:
  • Phone: 217-355-4753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209003769
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: