Provider Demographics
NPI:1649907296
Name:CAMPBELL, CANDACE DENISE (RDN)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:DENISE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 604050
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-4050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6371 JESSIE LN
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-9887
Practice Address - Country:US
Practice Address - Phone:336-740-9060
Practice Address - Fax:336-740-9659
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-03
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL006959133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered