Basic Information
| Provider Information | |||||||||
| NPI: | 1013320373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURNSIDE | ||||||||
| FirstName: | CANDICE | ||||||||
| MiddleName: | BRIANNE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 E JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724013119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702071630 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 225 E JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724013119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702071630 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2014 | ||||||||
| LastUpdateDate: | 05/07/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A004095 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 204689758 | 05 | AR | MEDICAID |