Provider Demographics
NPI:1194159442
Name:BOTTICELLO, CANDICE J (RN)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:J
Last Name:BOTTICELLO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 OLD CARRIAGE HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-3212
Mailing Address - Country:US
Mailing Address - Phone:716-773-6510
Mailing Address - Fax:
Practice Address - Street 1:418 3RD ST
Practice Address - Street 2:SUITE 101
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14301-1506
Practice Address - Country:US
Practice Address - Phone:716-205-8708
Practice Address - Fax:716-299-0374
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22579359163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse