Provider Demographics
NPI:1821778085
Name:GREGG, CANDACE AUTUMN (APRN)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:AUTUMN
Last Name:GREGG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 PHOENIX AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-1418
Mailing Address - Country:US
Mailing Address - Phone:203-756-8021
Mailing Address - Fax:
Practice Address - Street 1:80 PHOENIX AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1418
Practice Address - Country:US
Practice Address - Phone:203-756-8021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.012133363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily