Provider Demographics
NPI:1144656604
Name:WASOLASKUS, CANDICE LYN (RD)
Entity type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:LYN
Last Name:WASOLASKUS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 WEST SHERMAN AVENUE
Mailing Address - Street 2:BUILDING 2 UNIT C
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360
Mailing Address - Country:US
Mailing Address - Phone:856-362-5259
Mailing Address - Fax:856-407-6978
Practice Address - Street 1:1103 WEST SHERMAN AVENUE
Practice Address - Street 2:BUILDING 2 UNIT C
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360
Practice Address - Country:US
Practice Address - Phone:856-362-5259
Practice Address - Fax:856-407-6978
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1036618133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ60166181OtherHORIZON NJ HEALTH
NJ60166181OtherHORIZON NJ HEALTH