Provider Demographics
NPI:1932472172
Name:NATHANIEL, CANDICE KYLEEN
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:KYLEEN
Last Name:NATHANIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 GILLAM WAY # 1
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-6073
Mailing Address - Country:US
Mailing Address - Phone:907-799-1024
Mailing Address - Fax:
Practice Address - Street 1:110 2ND AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4809
Practice Address - Country:US
Practice Address - Phone:907-452-7946
Practice Address - Fax:907-452-7942
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH0157Medicaid
AKK0000WCHCPMedicare PIN