Healthcare Provider Details

I. General information

NPI: 1801370192
Provider Name (Legal Business Name): CANDICE MARIE VANN RDN LN CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

362 ANNIE GLADE DR
BOZEMAN MT
59718-7685
US

IV. Provider business mailing address

1043 STONERIDGE DR STE 2
BOZEMAN MT
59718-7084
US

V. Phone/Fax

Practice location:
  • Phone: 406-223-0820
  • Fax:
Mailing address:
  • Phone: 406-599-2492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberMED-NUTR-LIC-264
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberMED-NUTR-LIC-264
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: