MEDICARE: CANDICE PUCKETT KEY FNPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	201946	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467444679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CANDICE PUCKETT KEY FNPC

Provider Business Mailing Address
First Line	:	5306 NC HIGHWAY 55 STE 105
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27713-7812
Country	:	US
Telephone Number	:	919-457-1517
Fax Number	:	919-363-7697

Provider Business Practice Location Address
First Line	:	NEWSOME FAMILY PRACTICE
Second Line	:	304 MOUNTAINVIEW ROAD
City	:	KING
State	:	NC
Zip	:	27021
Country	:	US
Telephone Number	:	336-716-2255
Fax Number	:	336-983-3016

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	11/24/2021

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