Provider Demographics
NPI:1700593076
Name:KELLY, CANDACE P
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:P
Last Name:KELLY
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:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25708-0390
Mailing Address - Country:US
Mailing Address - Phone:304-429-1088
Mailing Address - Fax:304-429-3109
Practice Address - Street 1:1520 SLATE CREEK RD STE 201
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-6975
Practice Address - Country:US
Practice Address - Phone:276-242-2001
Practice Address - Fax:276-312-8337
Is Sole Proprietor?:No
Enumeration Date:2022-11-04
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185682363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily