Provider Demographics
NPI:1891132817
Name:PURVIS, CANDICE STAPLETON (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:STAPLETON
Last Name:PURVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:CANDICE
Other - Middle Name:GRACE
Other - Last Name:STAPLETON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:303 HARRIS INDUSTRIAL BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 HARRIS INDUSTRIAL BLVD STE 3
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8854
Practice Address - Country:US
Practice Address - Phone:912-537-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006802363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant