Provider Demographics
NPI:1871865113
Name:TILLMAN, CANDACE MARVENIA (RNC, MS, WHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:CANDACE
Middle Name:MARVENIA
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:RNC, MS, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 WINDSOR ST. SW
Mailing Address - Street 2:STE. 309
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312
Mailing Address - Country:US
Mailing Address - Phone:404-688-9202
Mailing Address - Fax:404-880-9435
Practice Address - Street 1:477 WINDSOR ST. SW
Practice Address - Street 2:STE. 309
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312
Practice Address - Country:US
Practice Address - Phone:404-688-9202
Practice Address - Fax:404-880-9435
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN142932207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN142932OtherSTATE OF GEORGIA