Healthcare Provider Details

I. General information

NPI: 1346347762
Provider Name (Legal Business Name): CANDACE RAINELLE RAW RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CANDACE RAINELLE CUNNINGHAM RN

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 STERTHAUS AVE
ORMOND BEACH FL
32174-5131
US

IV. Provider business mailing address

27 POSTVIEW DRIVE
PALM COAST FL
32164
US

V. Phone/Fax

Practice location:
  • Phone: 386-676-6081
  • Fax:
Mailing address:
  • Phone: 386-313-2850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN 9245885
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: