Provider Demographics
NPI:1144562620
Name:WALL, KANDACE MARIE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:KANDACE
Middle Name:MARIE
Last Name:WALL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 DYLAN PL
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40514-1062
Mailing Address - Country:US
Mailing Address - Phone:606-669-8601
Mailing Address - Fax:
Practice Address - Street 1:1792 ALYSHEBA WAY
Practice Address - Street 2:SUITE 150
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2288
Practice Address - Country:US
Practice Address - Phone:859-335-9041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007996363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily