Provider Demographics
NPI:1821124751
Name:HERON, CANDACE A (FNP)
Entity Type:Individual
Prefix:MS
First Name:CANDACE
Middle Name:A
Last Name:HERON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:A
Other - Last Name:HERON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:6386 GREELEY HILL RD
Mailing Address - Street 2:
Mailing Address - City:COULTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95311-9572
Mailing Address - Country:US
Mailing Address - Phone:209-878-0155
Mailing Address - Fax:
Practice Address - Street 1:6386 GREELEY HILL RD
Practice Address - Street 2:
Practice Address - City:COULTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95311-9572
Practice Address - Country:US
Practice Address - Phone:209-878-0155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF4621363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS94181Medicare UPIN