1114578168 NPI number — MRS. CANDANCE MARIE GUINN PMHNP-BC, APRN-CNP

Table of content: MRS. CANDANCE MARIE GUINN PMHNP-BC, APRN-CNP (NPI 1114578168)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114578168 NPI number — MRS. CANDANCE MARIE GUINN PMHNP-BC, APRN-CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUINN
Provider First Name:
CANDANCE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP-BC, APRN-CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114578168
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11898
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL DORADO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71730-0037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-639-9322
Provider Business Mailing Address Fax Number:
501-492-6477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1906 W HILLSBORO ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL DORADO
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-639-9322
Provider Business Practice Location Address Fax Number:
501-492-6477
Provider Enumeration Date:
09/20/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  122196 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 12296 . This is a "APRN LICENSE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 5FG01 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 14569857 . This is a "CAQH PROVIDER ID" identifier . This identifiers is of the category "OTHER".




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