1629637459 NPI number — CANDICE CAMILLE GREEN CLPN

Table of content: CANDICE CAMILLE GREEN CLPN (NPI 1629637459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629637459 NPI number — CANDICE CAMILLE GREEN CLPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
CANDICE
Provider Middle Name:
CAMILLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CLPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629637459
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5100 POPLAR AVE FL 27
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38137-2701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-815-0547
Provider Business Mailing Address Fax Number:
901-878-3181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5100 POPLAR AVE FL 27
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38137-2701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-815-0547
Provider Business Practice Location Address Fax Number:
901-878-3181
Provider Enumeration Date:
06/05/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  170003387 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 170003387 . This is a "BUSINESS LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".