Provider Demographics
NPI:1538670898
Name:HODGE, CANDICE R (NP, RN)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:R
Last Name:HODGE
Suffix:
Gender:F
Credentials:NP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 LONGFELLOW ST STE 200
Mailing Address - Street 2:
Mailing Address - City:VANDERGRIFT
Mailing Address - State:PA
Mailing Address - Zip Code:15690-1476
Mailing Address - Country:US
Mailing Address - Phone:724-568-5551
Mailing Address - Fax:724-568-3137
Practice Address - Street 1:224 LONGFELLOW ST STE 200
Practice Address - Street 2:
Practice Address - City:VANDERGRIFT
Practice Address - State:PA
Practice Address - Zip Code:15690-1476
Practice Address - Country:US
Practice Address - Phone:724-568-5551
Practice Address - Fax:724-568-3137
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017968363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103417383Medicaid