Provider Demographics
NPI:1477951630
Name:THOMAS, KANDACE JANELL
Entity Type:Individual
Prefix:
First Name:KANDACE
Middle Name:JANELL
Last Name:THOMAS
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 1:7618 APPOLINE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1106
Mailing Address - Country:US
Mailing Address - Phone:313-505-5455
Mailing Address - Fax:
Practice Address - Street 1:7618 APPOLINE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1106
Practice Address - Country:US
Practice Address - Phone:313-505-5455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703114471164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse