Provider Demographics
NPI:1548924012
Name:DE GUZMAN, CANDY GRACE JACOME
Entity type:Individual
Prefix:
First Name:CANDY GRACE
Middle Name:JACOME
Last Name:DE GUZMAN
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 1:12681 HASTER ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-6040
Mailing Address - Country:US
Mailing Address - Phone:714-971-2153
Mailing Address - Fax:
Practice Address - Street 1:12681 HASTER ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-6040
Practice Address - Country:US
Practice Address - Phone:714-971-2153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA950174472363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily