Provider Demographics
NPI:1013616069
Name:GROSS, CANDACE LANETTE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:LANETTE
Last Name:GROSS
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 1:3950 CORNELL ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38127-3867
Mailing Address - Country:US
Mailing Address - Phone:901-707-1778
Mailing Address - Fax:
Practice Address - Street 1:3950 CORNELL ST APT 1
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38127-3867
Practice Address - Country:US
Practice Address - Phone:901-707-1778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health