Provider Demographics
NPI:1891139259
Name:COBURN, CANDIDA LADAWN (MSN, RN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:CANDIDA
Middle Name:LADAWN
Last Name:COBURN
Suffix:
Gender:F
Credentials:MSN, RN, FNP-C
Other - Prefix:MRS
Other - First Name:CANDIDA
Other - Middle Name:LADAWN
Other - Last Name:SMEDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, RN, FNP-C
Mailing Address - Street 1:1600 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-2830
Mailing Address - Country:US
Mailing Address - Phone:575-396-6611
Mailing Address - Fax:575-396-1454
Practice Address - Street 1:1600 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-2830
Practice Address - Country:US
Practice Address - Phone:575-396-6611
Practice Address - Fax:575-396-1454
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02146363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54876079Medicaid
NM318166YNGGMedicare Oscar/Certification