Provider Demographics
NPI:1205404811
Name:VALLARTA, CANDACE MONIQUE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:MONIQUE
Last Name:VALLARTA
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 1:1161 N LOMBARD DR APT C
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-2181
Mailing Address - Country:US
Mailing Address - Phone:714-574-1547
Mailing Address - Fax:
Practice Address - Street 1:20342 FLANAGAN ROAD
Practice Address - Street 2:
Practice Address - City:TRABUCO CANYON
Practice Address - State:CA
Practice Address - Zip Code:92679
Practice Address - Country:US
Practice Address - Phone:818-582-8832
Practice Address - Fax:818-582-8836
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician