Provider Demographics
NPI:1285962605
Name:MOORE, CANDACE (NP)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:788 N JEFFERSON ST
Mailing Address - Street 2:SUITE 300 / ATTN. KAAREN BUTZEN
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3718
Mailing Address - Country:US
Mailing Address - Phone:414-272-8950
Mailing Address - Fax:414-272-0859
Practice Address - Street 1:13133 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE G-18
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2419
Practice Address - Country:US
Practice Address - Phone:262-243-5000
Practice Address - Fax:262-243-5026
Is Sole Proprietor?:No
Enumeration Date:2009-11-23
Last Update Date:2013-02-25
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Provider Licenses
StateLicense IDTaxonomies
WI3905363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1285962605Medicaid
WI1285962605Medicaid
WI736450071Medicare PIN