Healthcare Provider Details

I. General information

NPI: 1760081483
Provider Name (Legal Business Name): CONSTANCE M HENSHAW FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 04/16/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 W SMALL ST STE #1
HARRISBURG IL
62946
US

IV. Provider business mailing address

330 W SMALL ST STE 1
HARRISBURG IL
62946
US

V. Phone/Fax

Practice location:
  • Phone: 618-252-8535
  • Fax: 618-252-7920
Mailing address:
  • Phone: 618-252-8535
  • Fax: 618-252-7920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2090220809
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number2090220809
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: