Healthcare Provider Details

I. General information

NPI: 1316134315
Provider Name (Legal Business Name): CONSTANCE RENEE RIQUELME R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4449 STATE ROUTE 159
CHILLICOTHEE OH
45601-8620
US

IV. Provider business mailing address

4449 STATE ROUTE 159
CHILLICOTHEE OH
45601-8620
US

V. Phone/Fax

Practice location:
  • Phone: 740-772-7892
  • Fax: 740-773-1264
Mailing address:
  • Phone: 740-772-7892
  • Fax: 740-773-1264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberRN336844
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: