Provider Demographics
NPI:1215913439
Name:MCDOUGALL, CANDACE G (NP)
Entity type:Individual
Prefix:MS
First Name:CANDACE
Middle Name:G
Last Name:MCDOUGALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:CANDACE
Other - Middle Name:G
Other - Last Name:BELIVEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:300 STAFFORD STREET
Mailing Address - Street 2:SUITES 154, 161
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-2431
Mailing Address - Country:US
Mailing Address - Phone:413-732-1928
Mailing Address - Fax:413-734-1716
Practice Address - Street 1:300 STAFFORD STREET
Practice Address - Street 2:SUITES 154, 161
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2431
Practice Address - Country:US
Practice Address - Phone:413-732-1928
Practice Address - Fax:413-734-1716
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA146608363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0345661Medicaid
MA110015447AMedicaid
MA110015447AMedicaid
MANP1355Medicare PIN
MA0345661Medicaid