Provider Demographics
NPI:1558651117
Name:MADICK, CANDACE M (FNP)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:M
Last Name:MADICK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 ISLAND COTTAGE WAY
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-4404
Mailing Address - Country:US
Mailing Address - Phone:904-471-6629
Mailing Address - Fax:
Practice Address - Street 1:2703 N PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-2603
Practice Address - Country:US
Practice Address - Phone:904-824-2838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA12301-NP363LF0000X
FLARNP9268617363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicare PIN