Provider Demographics
NPI:1508577503
Name:CANADY, ABISOLA MORIAM (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:ABISOLA
Middle Name:MORIAM
Last Name:CANADY
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 OLD WAGNER RD BLDG D
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9313
Mailing Address - Country:US
Mailing Address - Phone:917-558-7986
Mailing Address - Fax:
Practice Address - Street 1:601 OLD WAGNER RD BLDG D
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9313
Practice Address - Country:US
Practice Address - Phone:804-835-9398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-09
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185894363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily