Provider Demographics
NPI:1982022349
Name:BERRY, CANDACE M
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:M
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 CATAMARAN CT
Mailing Address - Street 2:
Mailing Address - City:RIDGELEY
Mailing Address - State:WV
Mailing Address - Zip Code:26753-9768
Mailing Address - Country:US
Mailing Address - Phone:704-749-4060
Mailing Address - Fax:
Practice Address - Street 1:21 CATAMARAN CT
Practice Address - Street 2:
Practice Address - City:RIDGELEY
Practice Address - State:WV
Practice Address - Zip Code:26753-9768
Practice Address - Country:US
Practice Address - Phone:704-749-4060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVUD000316084001174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN