Provider Demographics
NPI:1215997028
Name:WILSON, CANDICE LYNN (MD)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11105
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37939-1105
Mailing Address - Country:US
Mailing Address - Phone:865-588-2928
Mailing Address - Fax:865-450-9374
Practice Address - Street 1:990 OAK RIDGE TPKE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6976
Practice Address - Country:US
Practice Address - Phone:865-835-4600
Practice Address - Fax:865-835-4609
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94386174400000X
TN0000037867174400000X
GA055042174400000X
AL00027018174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1882432OtherFIRST HEALTH
GA807388100Medicaid
TN9495633OtherCIGNA
KY7100041970Medicaid
TN4184755OtherBCBS OF TN
TN4184755OtherBCBS OF TN
GA807388100Medicaid
GA3638223998Medicare ID - Type Unspecified