Provider Demographics
NPI:1477954113
Name:WILSON, CANDACE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:WILSON
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 1:160 TWIN LAKES DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-9143
Mailing Address - Country:US
Mailing Address - Phone:360-560-8399
Mailing Address - Fax:
Practice Address - Street 1:160 TWIN LAKES DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-9143
Practice Address - Country:US
Practice Address - Phone:360-560-8399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide