Provider Demographics
NPI:1871902767
Name:KING, CANDICE (NP)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:
Other - Last Name:GIMENEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:625 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:CENTER MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11934
Mailing Address - Country:US
Mailing Address - Phone:631-878-7134
Mailing Address - Fax:631-878-5118
Practice Address - Street 1:625 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:CENTER MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11934
Practice Address - Country:US
Practice Address - Phone:631-878-7134
Practice Address - Fax:631-878-5118
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF306987-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health