Provider Demographics
NPI:1801495296
Name:MATASSA, CANDYSE ANNE (IBCLC)
Entity type:Individual
Prefix:MRS
First Name:CANDYSE
Middle Name:ANNE
Last Name:MATASSA
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18201 PINE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3473
Mailing Address - Country:US
Mailing Address - Phone:225-610-9217
Mailing Address - Fax:
Practice Address - Street 1:5848 MENLO DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-5047
Practice Address - Country:US
Practice Address - Phone:225-341-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-18
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-108612174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN