Healthcare Provider Details

I. General information

NPI: 1922559111
Provider Name (Legal Business Name): CANDACE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2016
Last Update Date: 10/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 OWEN DR
FAYETTEVILLE NC
28304-3424
US

IV. Provider business mailing address

1638 OWEN DR
FAYETTEVILLE NC
28304-3424
US

V. Phone/Fax

Practice location:
  • Phone: 910-615-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number113398
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: