Provider Demographics
NPI:1225169543
Name:MCKINNON, CANDICE CHRISTINA (CNA)
Entity Type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:CHRISTINA
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 773575
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-3575
Mailing Address - Country:US
Mailing Address - Phone:907-696-4433
Mailing Address - Fax:
Practice Address - Street 1:17250 PALOS VERDES DR
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-8133
Practice Address - Country:US
Practice Address - Phone:907-696-4433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK401722385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHC7062Medicaid