Provider Demographics
NPI:1154681039
Name:GLENN, CANDACE JORDAN (MD)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:JORDAN
Last Name:GLENN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4037 NW 86TH TER FL 4
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-9277
Mailing Address - Country:US
Mailing Address - Phone:352-594-1500
Mailing Address - Fax:352-594-1926
Practice Address - Street 1:4037 NW 86TH TER FL 4
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-9277
Practice Address - Country:US
Practice Address - Phone:352-594-1500
Practice Address - Fax:352-594-1926
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN17317207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology