Provider Demographics
NPI:1922256775
Name:JOHNSON, CANDY SUE (APN)
Entity Type:Individual
Prefix:MRS
First Name:CANDY
Middle Name:SUE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MISS
Other - First Name:CANDY
Other - Middle Name:SUE
Other - Last Name:WOLFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6940 MICHIGAN RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-2800
Mailing Address - Country:US
Mailing Address - Phone:317-221-3461
Mailing Address - Fax:
Practice Address - Street 1:6940 MICHIGAN RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-2800
Practice Address - Country:US
Practice Address - Phone:317-221-3461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-007187363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7200613OtherBLUE CROSS BLUE SHIELD