Provider Demographics
NPI:1033655907
Name:QUEEN, CANDICE (CRNA)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:QUEEN
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 1:5256 3RD AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-8115
Mailing Address - Country:US
Mailing Address - Phone:727-565-6568
Mailing Address - Fax:
Practice Address - Street 1:701 6TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4814
Practice Address - Country:US
Practice Address - Phone:727-823-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9320534367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered