Provider Demographics
NPI:1083025241
Name:THOMAS HARVEY, CANDACE ELEASE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:ELEASE
Last Name:THOMAS HARVEY
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:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:TERRY
Mailing Address - State:MS
Mailing Address - Zip Code:39170-0515
Mailing Address - Country:US
Mailing Address - Phone:601-983-7168
Mailing Address - Fax:769-251-1295
Practice Address - Street 1:105 E CUNNINGHAM ST SS
Practice Address - Street 2:
Practice Address - City:TERRY
Practice Address - State:MS
Practice Address - Zip Code:39170
Practice Address - Country:US
Practice Address - Phone:601-983-7168
Practice Address - Fax:769-257-5659
Is Sole Proprietor?:No
Enumeration Date:2014-05-09
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS385H00000X3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00503597Medicaid