Provider Demographics
NPI:1679261796
Name:BLAKE, CANDLER KIMSEY (MD)
Entity Type:Individual
Prefix:
First Name:CANDLER
Middle Name:KIMSEY
Last Name:BLAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CANDLER
Other - Middle Name:LORANN
Other - Last Name:KIMSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:208 ZURICH PL
Mailing Address - Street 2:
Mailing Address - City:SAUTEE NACOOCHEE
Mailing Address - State:GA
Mailing Address - Zip Code:30571-3508
Mailing Address - Country:US
Mailing Address - Phone:706-969-2970
Mailing Address - Fax:
Practice Address - Street 1:1350 S. KNGS DR
Practice Address - Street 2:3RD FLOOR
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207
Practice Address - Country:US
Practice Address - Phone:704-466-1242
Practice Address - Fax:704-446-1241
Is Sole Proprietor?:No
Enumeration Date:2023-04-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program