Provider Demographics
NPI:1407264971
Name:SHORT, CANDICE NICOLE (NP)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:NICOLE
Last Name:SHORT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:NICOLE
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:365 STOUT DRIVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-1703
Mailing Address - Country:US
Mailing Address - Phone:423-439-4515
Mailing Address - Fax:423-439-5780
Practice Address - Street 1:2151 CENTURY LN
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4469
Practice Address - Country:US
Practice Address - Phone:423-439-4515
Practice Address - Fax:423-439-5780
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19004363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ007448Medicaid