Healthcare Provider Details

I. General information

NPI: 1477736684
Provider Name (Legal Business Name): CANDICE M BOLLING P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16431 WISE ST
SAINT PAUL VA
24283-3537
US

IV. Provider business mailing address

1021 W OAKLAND AVE STE 310
JOHNSON CITY TN
37604-2192
US

V. Phone/Fax

Practice location:
  • Phone: 276-762-2300
  • Fax: 276-762-0612
Mailing address:
  • Phone: 423-302-6565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002673
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: