Provider Demographics
NPI:1407919822
Name:SHORT, CANDACE N (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:N
Last Name:SHORT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4370 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1056
Mailing Address - Country:US
Mailing Address - Phone:334-793-5000
Mailing Address - Fax:334-615-8418
Practice Address - Street 1:500 HEALTHWEST DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-6900
Practice Address - Country:US
Practice Address - Phone:334-699-5994
Practice Address - Fax:334-699-5995
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2023-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1079259174400000X
AL1-079259207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist