Provider Demographics
NPI:1558994491
Name:STALLWORTH, CANDICE SHERESE (MSN, PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:SHERESE
Last Name:STALLWORTH
Suffix:
Gender:F
Credentials:MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 MEDPARK DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-2288
Mailing Address - Country:US
Mailing Address - Phone:252-962-5410
Mailing Address - Fax:
Practice Address - Street 1:2301 MEDPARK DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2288
Practice Address - Country:US
Practice Address - Phone:252-962-5410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC232478163WP0808X
NC5013060363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health