Provider Demographics
NPI:1194383398
Name:WILLIAMS, CANDICE
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:WILLIAMS
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 1:377 HUNTINGTON PL
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-7965
Mailing Address - Country:US
Mailing Address - Phone:662-910-8391
Mailing Address - Fax:
Practice Address - Street 1:820 N GLOSTER ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-1949
Practice Address - Country:US
Practice Address - Phone:662-910-8391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224P00000X
MS5126721744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist