Provider Demographics
NPI:1336613579
Name:BUTLER GREEN, KANDYCE CHEVON
Entity Type:Individual
Prefix:
First Name:KANDYCE
Middle Name:CHEVON
Last Name:BUTLER GREEN
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 1:933 LOCKBOURNE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-1624
Mailing Address - Country:US
Mailing Address - Phone:614-209-3819
Mailing Address - Fax:
Practice Address - Street 1:1417 GAULT ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2900
Practice Address - Country:US
Practice Address - Phone:614-252-2328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health