Provider Demographics
NPI:1497268635
Name:GREGG, CANDICE PRISCILLA (ARNP)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:PRISCILLA
Last Name:GREGG
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:PRISCILLA
Other - Last Name:GREGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1401 CENTERVILLE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4638
Mailing Address - Country:US
Mailing Address - Phone:850-877-7241
Mailing Address - Fax:850-877-1338
Practice Address - Street 1:1401 CENTERVILLE RD STE 202
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4638
Practice Address - Country:US
Practice Address - Phone:850-877-7241
Practice Address - Fax:850-877-1338
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9324581363LX0001X
FLRN9324581363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023394800Medicaid