Healthcare Provider Details

I. General information

NPI: 1336780147
Provider Name (Legal Business Name): KRISTEN LEEANN CANADY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 OCEAN HWY W
SUPPLY NC
28462-4048
US

IV. Provider business mailing address

5864 N RHETT AVE APT 5B
HANAHAN SC
29410-2531
US

V. Phone/Fax

Practice location:
  • Phone: 910-356-6100
  • Fax:
Mailing address:
  • Phone: 252-558-3232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0010-09492
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: