Provider Demographics
NPI:1194423327
Name:KILLEEN, CANDICE M (CNM)
Entity type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:M
Last Name:KILLEEN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10748 W HIGH MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-8953
Mailing Address - Country:US
Mailing Address - Phone:479-595-5484
Mailing Address - Fax:
Practice Address - Street 1:214 S 1ST ST STE 203
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-4504
Practice Address - Country:US
Practice Address - Phone:479-935-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR219646367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty