Provider Demographics
NPI:1104860089
Name:COOLEY, CANDACE SUE (M D)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:SUE
Last Name:COOLEY
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 RACETRACK RD NE
Mailing Address - Street 2:SUITE D-2
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1882
Mailing Address - Country:US
Mailing Address - Phone:850-586-7661
Mailing Address - Fax:850-586-7679
Practice Address - Street 1:11 RACETRACK RD NE
Practice Address - Street 2:SUITE D-2
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1882
Practice Address - Country:US
Practice Address - Phone:850-586-7661
Practice Address - Fax:850-586-7679
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME77965207V00000X
CO47511207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG72623Medicare UPIN