Provider Demographics
NPI:1902689920
Name:STEPHENSON, KANDACE
Entity Type:Individual
Prefix:
First Name:KANDACE
Middle Name:
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 RIDGEBROOK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9477
Mailing Address - Country:US
Mailing Address - Phone:443-483-9300
Mailing Address - Fax:
Practice Address - Street 1:6047 TYVOLA GLEN CIR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-6431
Practice Address - Country:US
Practice Address - Phone:443-383-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5018629363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology