Provider Demographics
NPI:1891037305
Name:COLEMAN, CANDACE JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:JENNIFER
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1367 31ST AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-3946
Mailing Address - Country:US
Mailing Address - Phone:401-368-9277
Mailing Address - Fax:
Practice Address - Street 1:1367 31ST AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-3946
Practice Address - Country:US
Practice Address - Phone:401-368-9277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125062540207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
1891037305Medicare PIN
1891037305Medicare UPIN
1891037505Medicare NSC
IL1891037305Medicare Oscar/Certification