Provider Demographics
NPI:1073382065
Name:EASTMAN, CANDACE ANNE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:ANNE
Last Name:EASTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5975 W CHANDLER BLVD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-3422
Mailing Address - Country:US
Mailing Address - Phone:218-780-1175
Mailing Address - Fax:
Practice Address - Street 1:5975 W CHANDLER BLVD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-3422
Practice Address - Country:US
Practice Address - Phone:480-753-1826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-01
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11071363LF0000X
AZ235403363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily