Basic Information
| Provider Information | |||||||||
| NPI: | 1558619403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAFOE-RUEB | ||||||||
| FirstName: | CONSTANCE | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, RD, LD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAFOE-RUEB | ||||||||
| OtherFirstName: | CONNIE | ||||||||
| OtherMiddleName: | J. | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, RD, LD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4105 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669071068 | ||||||||
| FaxNumber: | 4259179141 | ||||||||
| Practice Location | |||||||||
| Address1: | 3220 PROVIDENCE DRIVE | ||||||||
| Address2: | E TOWER, SUITE 3030 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072127982 | ||||||||
| FaxNumber: | 9072127981 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2012 | ||||||||
| LastUpdateDate: | 04/26/2017 | ||||||||
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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 | 133V00000X | 291 | AK | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 1004022 | 05 | AK | MEDICAID |