Healthcare Provider Details

I. General information

NPI: 1316449820
Provider Name (Legal Business Name): CANDUS NICOLE ANTOLIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9923A E. JOHNSON ST MADIGAN ANNEX, JBLM
TACOMA WA
98498
US

IV. Provider business mailing address

9923A E. JOHNSON ST MADIGAN ANNEX, JBLM
TACOMA WA
98498
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-6485
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD-21233
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: