Provider Demographics
NPI:1700219060
Name:JOHNSON, CANDICE
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-3504
Mailing Address - Country:US
Mailing Address - Phone:347-866-6643
Mailing Address - Fax:
Practice Address - Street 1:2 ADAMS ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-3504
Practice Address - Country:US
Practice Address - Phone:347-866-6643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3093871164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3093871OtherNURSING LICENSE