Basic Information
| Provider Information | |||||||||
| NPI: | 1689621617 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIDDLE | ||||||||
| FirstName: | CONSTANCE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1512 E HARRY ST | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670028779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166408168 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3600 E HARRY ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672183713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162685775 | ||||||||
| FaxNumber: | 3162917496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 04/15/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 44492 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 200006200D | 05 | KS | MEDICAID |