Provider Demographics
NPI:1013457712
Name:FAHNER, CANDYCE (RN IBCLC)
Entity Type:Individual
Prefix:MS
First Name:CANDYCE
Middle Name:
Last Name:FAHNER
Suffix:
Gender:F
Credentials:RN IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 HAIG AVE
Mailing Address - Street 2:
Mailing Address - City:E PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772
Mailing Address - Country:US
Mailing Address - Phone:631-730-2993
Mailing Address - Fax:
Practice Address - Street 1:22 HAIG AVE
Practice Address - Street 2:
Practice Address - City:E PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-730-2993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRN309353163W00000X
NYL20013163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse