Provider Demographics
NPI:1326463985
Name:GUMMA, CANDACE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:GUMMA
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 1:17187 SCHAEFER HWY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-4132
Mailing Address - Country:US
Mailing Address - Phone:313-367-2767
Mailing Address - Fax:313-367-2818
Practice Address - Street 1:31333 SOUTHFIELD RD STE 130
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025-5473
Practice Address - Country:US
Practice Address - Phone:248-952-9190
Practice Address - Fax:248-952-9190
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704274496363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner