Provider Demographics
NPI:1962496554
Name:WATERS, CANDACE C (MSN, FNP-BC, CDE)
Entity type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:C
Last Name:WATERS
Suffix:
Gender:F
Credentials:MSN, FNP-BC, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 S. GULPH RD
Mailing Address - Street 2:ATT: IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:803-392-3724
Mailing Address - Fax:
Practice Address - Street 1:124 BETTIS ACADEMY RD
Practice Address - Street 2:
Practice Address - City:GRANITEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29829-3107
Practice Address - Country:US
Practice Address - Phone:803-392-3724
Practice Address - Fax:803-234-5593
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC459363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S16135Medicare UPIN
SCNP0189Medicaid
SCS161357058Medicare ID - Type Unspecified