Provider Demographics
NPI:1407242860
Name:AXEN, CANDANCE
Entity Type:Individual
Prefix:
First Name:CANDANCE
Middle Name:
Last Name:AXEN
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 1:970 W KING ST
Mailing Address - Street 2:WEST KING
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-8727
Mailing Address - Country:US
Mailing Address - Phone:904-466-4115
Mailing Address - Fax:
Practice Address - Street 1:970 W KING ST
Practice Address - Street 2:WEST KING
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-8727
Practice Address - Country:US
Practice Address - Phone:904-466-4115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL252741376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide