=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063225183
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CANDICE MARIE LASTER LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2025
-----------------------------------------------------
Last Update Date | 01/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 597 WESTRIDGE CIR
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30132-9236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-221-1369
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 552
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30132-0010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-221-1369
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | LPN086723
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------