Healthcare Provider Details

I. General information

NPI: 1295792331
Provider Name (Legal Business Name): CANDICE OGLINE RN, APN,C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2475 MCCLELLAN AVE
PENNSAUKEN NJ
08109-4683
US

IV. Provider business mailing address

2475 MCCLELLAN AVE LIFE AT LOURDES
PENNSAUKEN NJ
08109
US

V. Phone/Fax

Practice location:
  • Phone: 856-675-3660
  • Fax: 856-675-3659
Mailing address:
  • Phone: 856-675-3660
  • Fax: 856-675-3659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00039200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: