Basic Information
| Provider Information | |||||||||
| NPI: | 1154681039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLENN | ||||||||
| FirstName: | CANDACE | ||||||||
| MiddleName: | JORDAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4037 NW 86TH TER FL 4 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326069277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525941500 | ||||||||
| FaxNumber: | 3525941926 | ||||||||
| Practice Location | |||||||||
| Address1: | 4037 NW 86TH TER FL 4 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326069277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525941500 | ||||||||
| FaxNumber: | 3525941926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2012 | ||||||||
| LastUpdateDate: | 01/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | TRN17317 | FL | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.