Healthcare Provider Details

I. General information

NPI: 1598256497
Provider Name (Legal Business Name): CANDICE MIRANDA VALMONT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CANDICE MIRANDA GRANT MD

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E 6TH ST
TEXARKANA AR
71854-5207
US

IV. Provider business mailing address

3417 U OF A WAY
TEXARKANA AR
71854-1419
US

V. Phone/Fax

Practice location:
  • Phone: 870-799-6000
  • Fax: 870-799-6093
Mailing address:
  • Phone: 870-799-6000
  • Fax: 870-799-6093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number680132
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberE-12586
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberT4868
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: