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General NPI Number Information
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NPI Number | 1134798663
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Entity Type | Individual
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Provider Name | CONSTANCE FULLWOOD PHNL, PMHNP-BC
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Gender | Female
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Dates
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Enumeration Date | 06/19/2021
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Last Update Date | 11/01/2024
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Provider Practice Location Address
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Address Line | 36-11 21ST ST
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City | LONG ISLAND CITY
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State | NY
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Zip | 11106-4505
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Country | US
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Telephone | 718-482-7772
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Fax | 718-482-9648
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Provider Business Mailing Address
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Address Line | 60 MADISON AVE FL 5
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City | NEW YORK
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State | NY
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Zip | 10010-1600
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Country | US
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Telephone | 212-545-2400
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Fax | 212-463-8411
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | RN250856
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | F405449-01
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License Number State | NY
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