Provider Demographics
NPI:1639815376
Name:OMEGA, CANDICE
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:OMEGA
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 1:2521 INTERLOCK DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-2943
Mailing Address - Country:US
Mailing Address - Phone:407-780-9772
Mailing Address - Fax:
Practice Address - Street 1:2521 INTERLOCK DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2943
Practice Address - Country:US
Practice Address - Phone:407-780-9772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11018423363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care