Healthcare Provider Details

I. General information

NPI: 1285507053
Provider Name (Legal Business Name): CANDICE PARKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2025
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 GRIFFITHS AVE # 2F
LOUISVILLE KY
40203-1215
US

IV. Provider business mailing address

1391 DIXIE HWY
LOUISVILLE KY
40210-1772
US

V. Phone/Fax

Practice location:
  • Phone: 502-996-3922
  • Fax:
Mailing address:
  • Phone: 502-996-3922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: