Provider Demographics
NPI:1013320373
Name:BURNSIDE, CANDICE BRIANNE (APRN)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:BRIANNE
Last Name:BURNSIDE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 E JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3119
Mailing Address - Country:US
Mailing Address - Phone:870-207-1630
Mailing Address - Fax:
Practice Address - Street 1:225 E JACKSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3119
Practice Address - Country:US
Practice Address - Phone:870-207-1630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004095363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR204689758Medicaid
359890ZHXUMedicare UPIN