Healthcare Provider Details

I. General information

NPI: 1306271069
Provider Name (Legal Business Name): KANDACE LYN ELLER GNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2013
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4715 VIEWRIDGE AVE
SAN DIEGO CA
92123-1658
US

IV. Provider business mailing address

1404 FAIRFAX DR
LAFAYETTE IN
47909-3717
US

V. Phone/Fax

Practice location:
  • Phone: 800-257-8715
  • Fax:
Mailing address:
  • Phone: 765-430-0245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number28086571A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: