Provider Demographics
NPI:1447360482
Name:FORTUNE, CANDACE MERITA (MD)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:MERITA
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5480 SUR MER DR
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-7653
Mailing Address - Country:US
Mailing Address - Phone:707-235-9928
Mailing Address - Fax:
Practice Address - Street 1:785 ORCHARD DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-5557
Practice Address - Country:US
Practice Address - Phone:916-984-4300
Practice Address - Fax:916-984-4334
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA698122084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry