Healthcare Provider Details

I. General information

NPI: 1780747592
Provider Name (Legal Business Name): CONSTANCE JEAN STREET RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 KOT-NUM RD
WARM SPRINGS OR
97761
US

IV. Provider business mailing address

191 NE 11TH ST
MADRAS OR
97741-1832
US

V. Phone/Fax

Practice location:
  • Phone: 541-553-1196
  • Fax: 541-553-1130
Mailing address:
  • Phone: 541-815-2378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: