Provider Demographics
NPI:1760570790
Name:PHILLIPS, CANDACE T (RD)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:T
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52579 HIGHWAY 51 S
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:LA
Mailing Address - Zip Code:70443-2231
Mailing Address - Country:US
Mailing Address - Phone:985-878-1337
Mailing Address - Fax:
Practice Address - Street 1:52579 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:LA
Practice Address - Zip Code:70443-2231
Practice Address - Country:US
Practice Address - Phone:985-878-1337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1808133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C922Medicare ID - Type Unspecified