Provider Demographics
NPI:1790458982
Name:PHIFER, KANDICE LEIGH
Entity Type:Individual
Prefix:
First Name:KANDICE
Middle Name:LEIGH
Last Name:PHIFER
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 1:18495 DEVIN CT
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-5154
Mailing Address - Country:US
Mailing Address - Phone:304-993-1020
Mailing Address - Fax:
Practice Address - Street 1:1911 K M WICKER MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-5070
Practice Address - Country:US
Practice Address - Phone:919-439-9251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00670363A00000X
390200000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program