Provider Demographics
NPI:1306201728
Name:RICH, CANDRA (FNP)
Entity Type:Individual
Prefix:
First Name:CANDRA
Middle Name:
Last Name:RICH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307
Mailing Address - Country:US
Mailing Address - Phone:864-585-3608
Mailing Address - Fax:
Practice Address - Street 1:24 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:SC
Practice Address - Zip Code:29697-1925
Practice Address - Country:US
Practice Address - Phone:864-847-6020
Practice Address - Fax:864-847-6007
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8147208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC26-1367393Medicaid