Provider Demographics
NPI:1538921499
Name:HUTTO, CONSTANCE
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:HUTTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 RIDGE BROOK STA
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-8384
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6435 BELLS FERRY RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-2317
Practice Address - Country:US
Practice Address - Phone:770-926-4810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-26
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002753156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician