Provider Demographics
NPI:1518445782
Name:GONZALES, CANDACE (LVN)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2008 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78599-4359
Mailing Address - Country:US
Mailing Address - Phone:956-893-1040
Mailing Address - Fax:
Practice Address - Street 1:2102 W TEEGE AVE
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-4667
Practice Address - Country:US
Practice Address - Phone:956-412-3337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX182433164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1790847531Medicaid