Provider Demographics
NPI:1578813424
Name:REILY, CANDIS DAWN (CRNA)
Entity Type:Individual
Prefix:
First Name:CANDIS
Middle Name:DAWN
Last Name:REILY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 MONTEGUT ST
Mailing Address - Street 2:APT 215
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70117-7384
Mailing Address - Country:US
Mailing Address - Phone:678-637-2418
Mailing Address - Fax:
Practice Address - Street 1:522 MONTEGUT ST
Practice Address - Street 2:APT 215
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70117-7384
Practice Address - Country:US
Practice Address - Phone:678-637-2418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07003367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2316583Medicaid
MS07183797Medicaid
MS07183797Medicaid