Provider Demographics
NPI:1780382010
Name:CANIDATE, MYIA (LPN)
Entity type:Individual
Prefix:
First Name:MYIA
Middle Name:
Last Name:CANIDATE
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 1:650 PONCE DE LEON AVE NE STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-1864
Mailing Address - Country:US
Mailing Address - Phone:678-933-9367
Mailing Address - Fax:
Practice Address - Street 1:1001 VININGS TRL SE # 1001
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-8638
Practice Address - Country:US
Practice Address - Phone:678-933-9367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA098133164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA098133Medicaid