Provider Demographics
NPI:1881473759
Name:ANDERSON, CANDICE MARIE
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:MARIE
Other - Last Name:PRENTISS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3142 HORIZON RD STE 110
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-7810
Mailing Address - Country:US
Mailing Address - Phone:972-771-1171
Mailing Address - Fax:
Practice Address - Street 1:3142 HORIZON RD STE 110
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-7810
Practice Address - Country:US
Practice Address - Phone:972-771-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1138328363LA2100X
TX807483363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care