Healthcare Provider Details

I. General information

NPI: 1679685127
Provider Name (Legal Business Name): CONSTANCE JEANNE DERUNGS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CONSTANCE JEANNE BRANHAM & ELLER

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 S LAKE AVE SUITE 222
DULUTH MN
55802-2300
US

IV. Provider business mailing address

525 S LAKE AVE SUITE 222
DULUTH MN
55802-2300
US

V. Phone/Fax

Practice location:
  • Phone: 218-279-8372
  • Fax:
Mailing address:
  • Phone: 218-279-8372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 069317-4
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: