Basic Information
| Provider Information | |||||||||
| NPI: | 1730574450 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLSTON | ||||||||
| FirstName: | CANDACE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5665 NEW NORTHSIDE DR | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303285831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708746907 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 W MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301324117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4706447000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2015 | ||||||||
| LastUpdateDate: | 03/31/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN138876 | GA | N | Nursing Service Providers | Registered Nurse | 363L00000X | RN138876 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.