Provider Demographics
NPI:1265970719
Name:DESSELLE, CANDICE COCO (APRN)
Entity type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:COCO
Last Name:DESSELLE
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 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2713
Mailing Address - Fax:469-282-2665
Practice Address - Street 1:3330 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3841
Practice Address - Country:US
Practice Address - Phone:318-483-4090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-05
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN127478163W00000X
LAAP09177363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse