Provider Demographics
NPI:1417042847
Name:BROWN, CANDY GALE (LM, CLS)
Entity Type:Individual
Prefix:
First Name:CANDY
Middle Name:GALE
Last Name:BROWN
Suffix:
Gender:F
Credentials:LM, CLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 S OSCEOLA ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34465-3602
Mailing Address - Country:US
Mailing Address - Phone:352-270-8722
Mailing Address - Fax:
Practice Address - Street 1:47 S OSCEOLA ST
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-3602
Practice Address - Country:US
Practice Address - Phone:352-270-8722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2011-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW77176B00000X
FLTN0028829246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340032800Medicaid