Provider Demographics
NPI:1326416769
Name:TEAGUE, CANDICE (NP)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:CANDICE
Other - Middle Name:
Other - Last Name:TEAGUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:5350 TALLMAN AVE NW STE 520
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-5902
Practice Address - Country:US
Practice Address - Phone:206-215-4250
Practice Address - Fax:206-215-4252
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60594222363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner