Provider Demographics
NPI:1225697899
Name:VANDER WAL, CANDACE MARIE (MS, LAT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:MARIE
Last Name:VANDER WAL
Suffix:
Gender:F
Credentials:MS, LAT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 N 14TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-1611
Mailing Address - Country:US
Mailing Address - Phone:701-323-1125
Mailing Address - Fax:701-323-1180
Practice Address - Street 1:3451 N 14TH ST STE C
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-1611
Practice Address - Country:US
Practice Address - Phone:701-323-1125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND683-152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer