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General NPI Number Information
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NPI Number | 1558651117
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Entity Type | Individual
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Provider Name | CANDACE M MADICK FNP
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Gender | Female
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Dates
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Enumeration Date | 04/15/2011
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Last Update Date | 03/19/2012
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Provider Practice Location Address
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Address Line | 2703 N PONCE DE LEON BLVD
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City | ST AUGUSTINE
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State | FL
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Zip | 32084-2603
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Country | US
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Telephone | 904-824-2838
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Fax |
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Provider Business Mailing Address
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Address Line | 145 ISLAND COTTAGE WAY
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City | ST AUGUSTINE
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State | FL
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Zip | 32080-4404
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Country | US
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Telephone | 904-471-6629
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | COA12301-NP
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | ARNP9268617
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License Number State | FL
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