Healthcare Provider Details

I. General information

NPI: 1710307103
Provider Name (Legal Business Name): CANDACE WHITFIELD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 S SHIRLEY AVE
HONEA PATH SC
29654-1503
US

IV. Provider business mailing address

PO BOX 100174
COLUMBIA SC
29202-3174
US

V. Phone/Fax

Practice location:
  • Phone: 864-512-7879
  • Fax: 864-512-7037
Mailing address:
  • Phone: 864-369-0552
  • Fax: 864-369-1826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number18873
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number18773
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: