Provider Demographics
NPI:1619726882
Name:CROW GHOST, CANDACE ANNA
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:ANNA
Last Name:CROW GHOST
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 1:216 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4624
Mailing Address - Country:US
Mailing Address - Phone:701-204-2781
Mailing Address - Fax:
Practice Address - Street 1:216 N 14TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4624
Practice Address - Country:US
Practice Address - Phone:701-204-2781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-18
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X
ND171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach