Provider Demographics
NPI:1679024087
Name:DEBERRY, CANDACE BROOKE BOONE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:BROOKE BOONE
Last Name:DEBERRY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 W DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6307
Mailing Address - Country:US
Mailing Address - Phone:813-554-8387
Mailing Address - Fax:813-554-8937
Practice Address - Street 1:3001 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-554-8387
Practice Address - Fax:813-554-8937
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9233668363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily