Provider Demographics
NPI:1679010284
Name:TAYLOR, CANDACE MARIE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:MARIE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6128 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5832
Mailing Address - Country:US
Mailing Address - Phone:918-664-4224
Mailing Address - Fax:918-663-0203
Practice Address - Street 1:6128 E 38TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5832
Practice Address - Country:US
Practice Address - Phone:918-664-4224
Practice Address - Fax:918-663-0203
Is Sole Proprietor?:No
Enumeration Date:2017-01-22
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK043071771Medicaid