Provider Demographics
NPI:1801370192
Name:VANN, CANDICE MARIE (RDN LN CLC)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:MARIE
Last Name:VANN
Suffix:
Gender:F
Credentials:RDN LN CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 STONERIDGE DR STE 2
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-7084
Mailing Address - Country:US
Mailing Address - Phone:406-599-2492
Mailing Address - Fax:
Practice Address - Street 1:362 ANNIE GLADE DR
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-7685
Practice Address - Country:US
Practice Address - Phone:406-223-0820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-NUTR-LIC-264133V00000X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty