Provider Demographics
NPI:1063225183
Name:LASTER, CANDICE MARIE (LPN)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:MARIE
Last Name:LASTER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 552
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-0010
Mailing Address - Country:US
Mailing Address - Phone:678-221-1369
Mailing Address - Fax:
Practice Address - Street 1:597 WESTRIDGE CIR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-9236
Practice Address - Country:US
Practice Address - Phone:678-221-1369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN086723164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse