Healthcare Provider Details

I. General information

NPI: 1245194109
Provider Name (Legal Business Name): CANDACE BUTTS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

974 KLONDIKE CT SW STE 102
CONYERS GA
30094-5185
US

IV. Provider business mailing address

974 KLONDIKE CT SW STE 102
CONYERS GA
30094-5185
US

V. Phone/Fax

Practice location:
  • Phone: 678-680-3380
  • Fax:
Mailing address:
  • Phone: 678-680-3380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number139305
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number139305
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number139305
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: