Provider Demographics
NPI:1346910882
Name:GREEN, CANDACE L (IBCLC)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-1391
Mailing Address - Country:US
Mailing Address - Phone:706-814-8083
Mailing Address - Fax:
Practice Address - Street 1:1245 AUGUSTA WEST PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1807
Practice Address - Country:US
Practice Address - Phone:706-868-0389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-303750174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN