Provider Demographics
NPI:1275188393
Name:BENTLEY, CANDACE (APNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:APNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11414 W PARK PL STE 202
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-3500
Mailing Address - Country:US
Mailing Address - Phone:414-716-6394
Mailing Address - Fax:414-238-9489
Practice Address - Street 1:11414 W PARK PL STE 202
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-3500
Practice Address - Country:US
Practice Address - Phone:414-716-6394
Practice Address - Fax:414-238-9489
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9238-33363L00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100092110Medicaid