Healthcare Provider Details

I. General information

NPI: 1558994491
Provider Name (Legal Business Name): CANDICE SHERESE STALLWORTH MSN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 MEDPARK DR
ROCKY MOUNT NC
27804-2288
US

IV. Provider business mailing address

2301 MEDPARK DR
ROCKY MOUNT NC
27804-2288
US

V. Phone/Fax

Practice location:
  • Phone: 252-962-5410
  • Fax:
Mailing address:
  • Phone: 252-962-5410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number232478
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5013060
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: