Healthcare Provider Details

I. General information

NPI: 1366059347
Provider Name (Legal Business Name): CANDACE TICKLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 03/31/2024
Certification Date: 03/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12201 RESEARCH PKWY STE 300
ORLANDO FL
32826-3265
US

IV. Provider business mailing address

12201 RESEARCH PKWY STE 300
ORLANDO FL
32826-3265
US

V. Phone/Fax

Practice location:
  • Phone: 407-823-2744
  • Fax:
Mailing address:
  • Phone: 407-823-2744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPR11020311
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberC-APN.0004329-C-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: