Provider Demographics
NPI:1609632223
Name:CONSTANCE, SHADRIN K
Entity type:Individual
Prefix:
First Name:SHADRIN
Middle Name:K
Last Name:CONSTANCE
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 1:15780 ANDRIE ST NW
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303-3870
Mailing Address - Country:US
Mailing Address - Phone:651-353-9106
Mailing Address - Fax:
Practice Address - Street 1:464 2ND ST STE 204
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-2015
Practice Address - Country:US
Practice Address - Phone:612-787-8408
Practice Address - Fax:612-567-8935
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN238554-5163W00000X
MN12211363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse