Provider Demographics
NPI:1326349275
Name:ERSTAD, CANDICE C (MS, RD)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:C
Last Name:ERSTAD
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:R
Other - Last Name:CANDELARIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD
Mailing Address - Street 1:2850 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-1004
Mailing Address - Country:US
Mailing Address - Phone:602-266-5976
Mailing Address - Fax:602-274-8952
Practice Address - Street 1:2850 N 24TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-1004
Practice Address - Country:US
Practice Address - Phone:602-266-5976
Practice Address - Fax:602-274-8952
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ799494Medicaid