Provider Demographics
NPI:1023550894
Name:MALONE, CANDACE GREGORY (NP)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:GREGORY
Last Name:MALONE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:151 PEACHWOOD CENTRE DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-2575
Practice Address - Country:US
Practice Address - Phone:864-560-9627
Practice Address - Fax:864-562-5470
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC105935163W00000X
SC20628363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC9726J577OtherMEDICARE PIN
SCSC97266084OtherMEDICARE PTAN
SCSC97266121OtherMEDICARE PIN
SCNP4260Medicaid