Provider Demographics
NPI:1194275891
Name:SROKA, CONSTANCE C (RD, CDE)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:C
Last Name:SROKA
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32255 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 30
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-1566
Mailing Address - Country:US
Mailing Address - Phone:248-851-1419
Mailing Address - Fax:
Practice Address - Street 1:32255 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 30
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-1566
Practice Address - Country:US
Practice Address - Phone:248-851-1419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI490855133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N63810Medicare PIN