Provider Demographics
NPI:1003047804
Name:FUNDERBURK, CANDACE M (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:M
Last Name:FUNDERBURK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 DESS RD
Mailing Address - Street 2:
Mailing Address - City:FLORIEN
Mailing Address - State:LA
Mailing Address - Zip Code:71429-4267
Mailing Address - Country:US
Mailing Address - Phone:318-586-4621
Mailing Address - Fax:
Practice Address - Street 1:881 DESS RD
Practice Address - Street 2:
Practice Address - City:FLORIEN
Practice Address - State:LA
Practice Address - Zip Code:71429-4267
Practice Address - Country:US
Practice Address - Phone:318-586-4621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA074290367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered