Provider Demographics
NPI:1891242921
Name:SHIRLEY, CANDACE (NP-C)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12855 N 40 DR STE 205
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8670
Mailing Address - Country:US
Mailing Address - Phone:314-720-0900
Mailing Address - Fax:
Practice Address - Street 1:456 N NEW BALLAS RD STE 348
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6846
Practice Address - Country:US
Practice Address - Phone:314-548-0265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016018345363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily