Provider Demographics
NPI:1811636822
Name:SULLIVAN, CANDICE DARCHELL
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:DARCHELL
Last Name:SULLIVAN
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 1:2933 RATON PATH
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-2980
Mailing Address - Country:US
Mailing Address - Phone:678-469-0490
Mailing Address - Fax:
Practice Address - Street 1:1520 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-4201
Practice Address - Country:US
Practice Address - Phone:404-727-7980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN242143163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse