Provider Demographics
NPI:1255831368
Name:GREEN, CANDACE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:GREEN
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 1:3301 TALL PNES
Mailing Address - Street 2:
Mailing Address - City:PINE HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-7615
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3301 TALL PNES
Practice Address - Street 2:
Practice Address - City:PINE HILL
Practice Address - State:NJ
Practice Address - Zip Code:08021-7615
Practice Address - Country:US
Practice Address - Phone:609-617-2320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP06651700164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse