Provider Demographics
NPI:1285268367
Name:CANERDY, CANDACE NICOLE (LAC)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:NICOLE
Last Name:CANERDY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-0767
Mailing Address - Country:US
Mailing Address - Phone:901-277-9791
Mailing Address - Fax:
Practice Address - Street 1:1170 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-0767
Practice Address - Country:US
Practice Address - Phone:901-277-9791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONCC172880171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist