Healthcare Provider Details

I. General information

NPI: 1629407549
Provider Name (Legal Business Name): CANDACE M. WALKER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CANDACE M. LANE

II. Dates (important events)

Enumeration Date: 11/01/2013
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5610 WENDY BAGWELL PKWY
HIRAM GA
30141-7837
US

IV. Provider business mailing address

601 S HARBOUR ISLAND BLVD STE 200
TAMPA FL
33602-5925
US

V. Phone/Fax

Practice location:
  • Phone: 770-943-7808
  • Fax: 770-943-7805
Mailing address:
  • Phone: 800-480-5243
  • Fax: 800-928-7449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number070925
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: