Provider Demographics
NPI:1023012663
Name:BROWN, CANDACE SUSANNE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:CANDACE
Middle Name:SUSANNE
Last Name:BROWN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:66 N PAULINE ST
Mailing Address - Street 2:ROOM 501
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-5105
Mailing Address - Country:US
Mailing Address - Phone:901-867-0739
Mailing Address - Fax:901-448-1741
Practice Address - Street 1:66 N PAULINE ST
Practice Address - Street 2:ROOM 501
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-5105
Practice Address - Country:US
Practice Address - Phone:901-867-0739
Practice Address - Fax:901-448-1741
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNAPN0000006384363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNS37672Medicare UPIN
TN3343661Medicare PIN