Healthcare Provider Details

I. General information

NPI: 1962063636
Provider Name (Legal Business Name): CANDICE NICOLE TATE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44617 S AIRPORT RD
HAMMOND LA
70403-0311
US

IV. Provider business mailing address

13308 MOSS POINT DR APT A
HAMMOND LA
70401-6448
US

V. Phone/Fax

Practice location:
  • Phone: 985-429-7611
  • Fax:
Mailing address:
  • Phone: 985-215-1365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: