MEDICARE: CANDACE GUMMA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	4704274496	MI

General Provider Information

NPI Number	:	1326463985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CANDACE GUMMA

Provider Business Mailing Address
First Line	:	17187 SCHAEFER HWY
Second Line	:	SUITE 4
City	:	DETROIT
State	:	MI
Zip	:	48235-4132
Country	:	US
Telephone Number	:	313-367-2767
Fax Number	:	313-367-2818

Provider Business Practice Location Address
First Line	:	31333 SOUTHFIELD RD STE 130
Second Line	:
City	:	BEVERLY HILLS
State	:	MI
Zip	:	48025-5473
Country	:	US
Telephone Number	:	248-952-9190
Fax Number	:	248-952-9190

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2014
Last Update Date	:	04/01/2019

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