Provider Demographics
NPI:1467484980
Name:WOMMACK, KANDICE JOETTE (DC)
Entity Type:Individual
Prefix:DR
First Name:KANDICE
Middle Name:JOETTE
Last Name:WOMMACK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 VINE ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-7472
Mailing Address - Country:US
Mailing Address - Phone:270-527-0000
Mailing Address - Fax:270-527-2121
Practice Address - Street 1:142 VINE ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-7472
Practice Address - Country:US
Practice Address - Phone:270-527-0000
Practice Address - Fax:270-527-2121
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4556111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY614099OtherACN
KY44-00390OtherUHC
KY7670104OtherAETNA
KY000000077520OtherANTHRM BCBS
KY350052669OtherRAILROAD MEDICARE
KY350052669OtherRAILROAD MEDICARE
KY44-00390OtherUHC