Healthcare Provider Details

I. General information

NPI: 1508690751
Provider Name (Legal Business Name): CANDICE OWENS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2024
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 OLD WINDER HWY
BRASELTON GA
30517-6105
US

IV. Provider business mailing address

5050 SUNRISE LN
CUMMING GA
30041-2314
US

V. Phone/Fax

Practice location:
  • Phone: 678-821-2401
  • Fax:
Mailing address:
  • Phone: 404-803-7296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN201321
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: