Provider Demographics
NPI:1558067561
Name:PURNELL, CANDICE (PTA)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:PURNELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:33 N MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18640-1949
Mailing Address - Country:US
Mailing Address - Phone:570-208-2787
Mailing Address - Fax:570-208-2788
Practice Address - Street 1:40 W NORTHAMPTON ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-1775
Practice Address - Country:US
Practice Address - Phone:570-307-2775
Practice Address - Fax:570-307-2776
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PATE012002225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant