Provider Demographics
NPI:1275703498
Name:WAMPLER, CANDICE MARIE
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:MARIE
Last Name:WAMPLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10121 EVERGREEN WAY # 315
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-3885
Mailing Address - Country:US
Mailing Address - Phone:425-508-7331
Mailing Address - Fax:
Practice Address - Street 1:29288 218TH PL SE
Practice Address - Street 2:
Practice Address - City:BLACK DIAMOND
Practice Address - State:WA
Practice Address - Zip Code:98010-1266
Practice Address - Country:US
Practice Address - Phone:360-886-8886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00006922171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00006922OtherMASSAGE THERAPIST