Healthcare Provider Details

I. General information

NPI: 1427575703
Provider Name (Legal Business Name): NOVA CANDICE JENNINGS RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HURLEY PLZ
FLINT MI
48503-5902
US

IV. Provider business mailing address

2339 DELWOOD DR
CLIO MI
48420-9158
US

V. Phone/Fax

Practice location:
  • Phone: 810-262-9580
  • Fax:
Mailing address:
  • Phone: 810-625-8613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number4704185932
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: