Provider Demographics
NPI:1801102371
Name:LOVE, CANDISE ANN (RN)
Entity type:Individual
Prefix:
First Name:CANDISE
Middle Name:ANN
Last Name:LOVE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1231 PINE GROVE AVE
Mailing Address - Street 2:STE 2F
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3500
Mailing Address - Country:US
Mailing Address - Phone:810-982-5200
Mailing Address - Fax:
Practice Address - Street 1:1231 PINE GROVE AVE
Practice Address - Street 2:STE 2F
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3500
Practice Address - Country:US
Practice Address - Phone:810-982-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704261280163WX0200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WX0200XNursing Service ProvidersRegistered NurseOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1801102371Medicaid
MIN52480007Medicare PIN