Healthcare Provider Details

I. General information

NPI: 1467476440
Provider Name (Legal Business Name): SUSAN CONSTANCE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 09/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 NORTH MUNDO
DULCE NM
87528-0269
US

IV. Provider business mailing address

PO BOX 269
DULCE NM
87528-0269
US

V. Phone/Fax

Practice location:
  • Phone: 505-759-3291
  • Fax: 505-759-7294
Mailing address:
  • Phone: 505-759-1691
  • Fax: 505-759-7294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number126420
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: