Provider Demographics
NPI:1922231455
Name:BURGOYNE, CANDACE CARREEN (RN, CPNP)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:CARREEN
Last Name:BURGOYNE
Suffix:
Gender:F
Credentials:RN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201A HILL RD
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78957-9533
Mailing Address - Country:US
Mailing Address - Phone:512-360-5272
Mailing Address - Fax:512-360-5273
Practice Address - Street 1:1201A HILL RD
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:TX
Practice Address - Zip Code:78957-9533
Practice Address - Country:US
Practice Address - Phone:512-360-5272
Practice Address - Fax:512-360-5273
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX243170363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092067003Medicaid
TX8L19766Medicare PIN