Provider Demographics
NPI:1760845606
Name:MALDONADO, CANDICE ELISE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:ELISE
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2368 MEADOWMONT DR APT 401
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95133-1253
Mailing Address - Country:US
Mailing Address - Phone:336-331-7600
Mailing Address - Fax:
Practice Address - Street 1:9245 S MINGO RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5793
Practice Address - Country:US
Practice Address - Phone:918-574-0250
Practice Address - Fax:918-574-0259
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK99434363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200646430AMedicaid