Healthcare Provider Details

I. General information

NPI: 1922284504
Provider Name (Legal Business Name): CANDACE DONYUSHA CHARLES PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CANDACE DONYUSHA MOSES

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4965 STONE FALLS CTR STE 7
O FALLON IL
62269-7803
US

IV. Provider business mailing address

3 PROFESSIONAL DR STE B
ALTON IL
62002-5067
US

V. Phone/Fax

Practice location:
  • Phone: 618-726-2500
  • Fax:
Mailing address:
  • Phone: 618-465-7177
  • Fax: 618-465-7176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004583
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: