Provider Demographics
NPI:1003201211
Name:CANDACE M FUNDERBURK
Entity Type:Organization
Organization Name:CANDACE M FUNDERBURK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FUNDERBURK
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:318-508-2009
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:
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:318-508-2009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA074290367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty