Provider Demographics
NPI:1841745312
Name:TAN, CANDICE ANN ANG (MMS, PA-C, RD)
Entity Type:Individual
Prefix:
First Name:CANDICE ANN
Middle Name:ANG
Last Name:TAN
Suffix:
Gender:F
Credentials:MMS, PA-C, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1645 W SCHOOL ST STE A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2171
Mailing Address - Country:US
Mailing Address - Phone:773-227-3669
Mailing Address - Fax:
Practice Address - Street 1:1645 W SCHOOL ST STE A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2171
Practice Address - Country:US
Practice Address - Phone:773-227-3669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2020-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.006556133V00000X
IL085.007706363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered