Provider Demographics
NPI:1528110137
Name:WANTLING, CONSTANCE (CRNP)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:WANTLING
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 SOLAREX COURT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:56 THOMAS JOHNSON DR
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4599
Practice Address - Country:US
Practice Address - Phone:301-694-3111
Practice Address - Fax:301-694-8626
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR152452363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD926580503Medicaid
MD926580505Medicaid
MDCD8143Medicare PIN
MD239013ZCSVMedicare PIN
MD926580505Medicaid