Individual
CANDRA LANETTE MACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
4152 BAKER STREET, NE, COVINGTON, GA 30014-1404
(770) 788-1077
(770) 805-9329
Mailing address
4152 BAKER STREET, NE, COVINGTON, GA 30014-1404
(770) 788-1077
(770) 805-9329
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
61000
GA
208000000X
Pediatrics Physician
TRN8908
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
061000
MEDICAL LICENSE
GA
05
—
510091718A
—
GA
Enumeration date
01/10/2007
Last updated
03/07/2023
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