Healthcare Provider Details

I. General information

NPI: 1104320803
Provider Name (Legal Business Name): CANDICE CAMPBELL APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 03/07/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 JOE AVE
HOHENWALD TN
38462-2002
US

IV. Provider business mailing address

912 W COLLEGE ST
PULASKI TN
38478-3630
US

V. Phone/Fax

Practice location:
  • Phone: 931-796-9797
  • Fax: 931-295-0200
Mailing address:
  • Phone: 931-424-9797
  • Fax: 931-424-9788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number24040
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number24040
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: