Provider Demographics
NPI:1588053730
Name:CAILLOUETTE, CANDICE HOLLY (RN)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:HOLLY
Last Name:CAILLOUETTE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1343 14TH ST APT D
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1754
Mailing Address - Country:US
Mailing Address - Phone:858-229-9226
Mailing Address - Fax:
Practice Address - Street 1:1316 3RD STREET PROMENADE STE 201
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1382
Practice Address - Country:US
Practice Address - Phone:213-284-3118
Practice Address - Fax:310-395-3628
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA720708163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse