Provider Demographics
NPI:1861796625
Name:THOMAS, CONSTANCE SMYTH (NP)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:SMYTH
Last Name:THOMAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-2743
Mailing Address - Country:US
Mailing Address - Phone:217-355-4753
Mailing Address - Fax:
Practice Address - Street 1:4545 E SHEA BLVD
Practice Address - Street 2:SUITE 175
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3074
Practice Address - Country:US
Practice Address - Phone:602-464-5251
Practice Address - Fax:480-907-2108
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003769363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily