Provider Demographics
NPI:1124653522
Name:CONGLETON, CANDACE LEE
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:LEE
Last Name:CONGLETON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PECAN GAP
Mailing Address - State:TX
Mailing Address - Zip Code:75469-9604
Mailing Address - Country:US
Mailing Address - Phone:903-359-6401
Mailing Address - Fax:
Practice Address - Street 1:204 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PECAN GAP
Practice Address - State:TX
Practice Address - Zip Code:75469-9604
Practice Address - Country:US
Practice Address - Phone:903-359-6401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider