Healthcare Provider Details

I. General information

NPI: 1689941817
Provider Name (Legal Business Name): CANDACE L. PERCIFULL APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2011
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 EUBANK BLVD NE
ALBUQUERQUE NM
87111
US

IV. Provider business mailing address

6704 SUERTE PL NE
ALBUQUERQUE NM
87113-1956
US

V. Phone/Fax

Practice location:
  • Phone: 505-292-8575
  • Fax:
Mailing address:
  • Phone: 870-239-1282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA03615
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP02074
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: