Provider Demographics
NPI:1144856279
Name:MCKINNIES, CANDACE (CPT)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:MCKINNIES
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 ESTHER ST
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-3509
Mailing Address - Country:US
Mailing Address - Phone:504-513-1273
Mailing Address - Fax:
Practice Address - Street 1:110 BELLEMEADE BLVD STE B
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-7143
Practice Address - Country:US
Practice Address - Phone:504-400-6676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X, 261QH0100X
LA2472E0500X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No171W00000XOther Service ProvidersContractor
No2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service