Healthcare Provider Details

I. General information

NPI: 1639050321
Provider Name (Legal Business Name): CANDICE LYNN MOREAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CANDICE LYNN DEGRAND

II. Dates (important events)

Enumeration Date: 09/09/2025
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 S WEBSTER AVE
GREEN BAY WI
54301-3505
US

IV. Provider business mailing address

5060 KILRENNY CT
NEW FRANKEN WI
54229-9632
US

V. Phone/Fax

Practice location:
  • Phone: 920-433-3617
  • Fax:
Mailing address:
  • Phone: 920-360-2509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number150128
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: