Provider Demographics
NPI:1497991343
Name:ISOM, CANDICE M (LMP)
Entity Type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:M
Last Name:ISOM
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23410 E MISSION AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-7515
Mailing Address - Country:US
Mailing Address - Phone:509-999-4780
Mailing Address - Fax:509-924-8242
Practice Address - Street 1:23410 E MISSION AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-7515
Practice Address - Country:US
Practice Address - Phone:509-999-4780
Practice Address - Fax:509-924-8242
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-24
Last Update Date:2008-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019234225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist