Provider Demographics
NPI:1629637459
Name:GREEN, CANDICE CAMILLE (CLPN)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:CAMILLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:CLPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 POPLAR AVE FL 27
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38137-2701
Mailing Address - Country:US
Mailing Address - Phone:662-815-0547
Mailing Address - Fax:901-878-3181
Practice Address - Street 1:5100 POPLAR AVE FL 27
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38137-2701
Practice Address - Country:US
Practice Address - Phone:662-815-0547
Practice Address - Fax:901-878-3181
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN170003387251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN170003387OtherBUSINESS LICENSE