Healthcare Provider Details

I. General information

NPI: 1578553962
Provider Name (Legal Business Name): CANDACE MCKNIGHT JOHNSON CRNP F MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 12/01/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5717 21ST AVE W
BRADENTON FL
34209
US

IV. Provider business mailing address

5717 21ST AVE W
BRADENTON FL
34209
US

V. Phone/Fax

Practice location:
  • Phone: 941-792-8383
  • Fax: 941-792-8484
Mailing address:
  • Phone: 941-792-8383
  • Fax: 941-792-8484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0000453
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9495576
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR097401
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: