Provider Demographics
NPI:1336496868
Name:LYTTON, KANDICE MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:KANDICE
Middle Name:MARIE
Last Name:LYTTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:KANDICE
Other - Middle Name:MARIE
Other - Last Name:LESOFSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 9TH ST. NO.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2279
Mailing Address - Country:US
Mailing Address - Phone:218-749-9405
Mailing Address - Fax:218-749-9407
Practice Address - Street 1:901 9TH ST. NO.
Practice Address - Street 2:SUITE 100
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2279
Practice Address - Country:US
Practice Address - Phone:218-749-9405
Practice Address - Fax:218-749-9407
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9048225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist