Healthcare Provider Details

I. General information

NPI: 1730731043
Provider Name (Legal Business Name): CANDICE H WILD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 N HIGHWAY 190
COVINGTON LA
70433-5364
US

IV. Provider business mailing address

PO BOX 3370
COVINGTON LA
70434-3370
US

V. Phone/Fax

Practice location:
  • Phone: 985-892-5355
  • Fax: 985-256-5687
Mailing address:
  • Phone: 985-400-5988
  • Fax: 985-256-5687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number204744
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: