Provider Demographics
NPI:1447596705
Name:CHILDRESS, CANDICE D
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:D
Last Name:CHILDRESS
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 1:1946 ONA MARIE AVE
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-4867
Mailing Address - Country:US
Mailing Address - Phone:702-488-2559
Mailing Address - Fax:
Practice Address - Street 1:1946 ONA MARIE AVE
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-4867
Practice Address - Country:US
Practice Address - Phone:702-488-2559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker