Provider Demographics
NPI:1811092810
Name:TULL, CANDACE MARIE (PHD, WHCNP)
Entity type:Individual
Prefix:DR
First Name:CANDACE
Middle Name:MARIE
Last Name:TULL
Suffix:
Gender:F
Credentials:PHD, WHCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 62 BOX 7466
Mailing Address - Street 2:
Mailing Address - City:STAR VALLEY RANCH
Mailing Address - State:WY
Mailing Address - Zip Code:83127-7004
Mailing Address - Country:US
Mailing Address - Phone:210-215-5222
Mailing Address - Fax:
Practice Address - Street 1:107736 HWY 89
Practice Address - Street 2:
Practice Address - City:ETNA
Practice Address - State:WY
Practice Address - Zip Code:83118
Practice Address - Country:US
Practice Address - Phone:210-215-5222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY30706.1178363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health