Healthcare Provider Details

I. General information

NPI: 1669984191
Provider Name (Legal Business Name): CANDICE R NERVEZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 12/26/2019
Certification Date: 12/26/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MEDICAL DR STE D101
BOUNTIFUL UT
84010-8905
US

IV. Provider business mailing address

17 PONI MOI PL
HILO HI
96720-1739
US

V. Phone/Fax

Practice location:
  • Phone: 801-683-1062
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number11939539
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: