Provider Demographics
NPI:1881832558
Name:WHITELY, CANDICE D (NP)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:D
Last Name:WHITELY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8390 CHAMPIONS GATE BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:CHAMPIONS GATE
Mailing Address - State:FL
Mailing Address - Zip Code:33896-8310
Mailing Address - Country:US
Mailing Address - Phone:407-390-1677
Mailing Address - Fax:407-390-1765
Practice Address - Street 1:4940 VAN NUYS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403
Practice Address - Country:US
Practice Address - Phone:818-380-2626
Practice Address - Fax:818-380-2620
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA95004880363LF0000X
NY335778363LF0000X
FL9295215363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00756650OtherRAILROAD MEDICARE
FLCH323ZMedicare PIN