Healthcare Provider Details

I. General information

NPI: 1205980505
Provider Name (Legal Business Name): CONSTANCE CUSTER RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 NE 19TH CT UNIT G-118
WILTON MANORS FL
33305-1043
US

IV. Provider business mailing address

PO BOX 23007
FORT LAUDERDALE FL
33307-3007
US

V. Phone/Fax

Practice location:
  • Phone: 954-873-4822
  • Fax: 954-390-0420
Mailing address:
  • Phone: 954-227-8224
  • Fax: 954-227-7442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN1698912
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: