Healthcare Provider Details

I. General information

NPI: 1578241469
Provider Name (Legal Business Name): CANDICE FORD CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 03/15/2026
Certification Date: 03/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 W SWEETWATER DR
TUCSON AZ
85745-9348
US

IV. Provider business mailing address

1315 E 12TH ST
TUCSON AZ
85719-6155
US

V. Phone/Fax

Practice location:
  • Phone: 509-876-1638
  • Fax:
Mailing address:
  • Phone: 150-987-6163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1578241469
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: