Provider Demographics
NPI:1730051608
Name:PHILLIPS, CANDICE T (DRPH)
Entity type:Individual
Prefix:MS
First Name:CANDICE
Middle Name:T
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:DRPH
Other - Prefix:
Other - First Name:TEENA
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2612 E MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-6032
Mailing Address - Country:US
Mailing Address - Phone:901-352-8566
Mailing Address - Fax:
Practice Address - Street 1:2612 E MONROE AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-6032
Practice Address - Country:US
Practice Address - Phone:901-352-8566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-20
Last Update Date:2025-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
105121173000000X
AR105121261QR1100X
AR908464201347C00000X
MN2901552390200000X
AR2657421246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No173000000XOther Service ProvidersLegal Medicine
No261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch
No347C00000XTransportation ServicesPrivate Vehicle
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program