Provider Demographics
NPI:1336579796
Name:MENDOZA, CANDACE (NP)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:
Other - Last Name:ENGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:11350 MCCORMICK ROAD
Mailing Address - Street 2:EXECUTIVE PLAZA 1, SUITE 501
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031-8732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2080 W ARLINGTON BLVD STE A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3770
Practice Address - Country:US
Practice Address - Phone:252-689-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-22
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008356363L00000X
NC5008800363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100271570Medicaid
KYK097910Medicare PIN