Provider Demographics
NPI:1558619403
Name:DAFOE-RUEB, CONSTANCE J (MS, RD, LD)
Entity type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:J
Last Name:DAFOE-RUEB
Suffix:
Gender:
Credentials:MS, RD, LD
Other - Prefix:MRS
Other - First Name:CONNIE
Other - Middle Name:J
Other - Last Name:DAFOE-RUEB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, RD, LD
Mailing Address - Street 1:3801 LAKE OTIS PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5234
Mailing Address - Country:US
Mailing Address - Phone:907-562-2277
Mailing Address - Fax:907-563-3460
Practice Address - Street 1:4100 LAKE OTIS PKWY STE 322
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5231
Practice Address - Country:US
Practice Address - Phone:907-562-1234
Practice Address - Fax:907-677-2007
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK291133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1004022Medicaid
AKK164651Medicare PIN