Provider Demographics
NPI:1689192767
Name:SMITH, CANDREA (FNP-C)
Entity Type:Individual
Prefix:
First Name:CANDREA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 HEATHLAND TRL
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MD
Mailing Address - Zip Code:21001-3651
Mailing Address - Country:US
Mailing Address - Phone:443-570-8289
Mailing Address - Fax:
Practice Address - Street 1:504 LEWIS ST
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3420
Practice Address - Country:US
Practice Address - Phone:443-502-5311
Practice Address - Fax:443-955-5736
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR184963207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine