Provider Demographics
NPI:1588651863
Name:HANAFIN VICE, KANDY LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:KANDY
Middle Name:LYNN
Last Name:HANAFIN VICE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:KANDY
Other - Middle Name:LYNN
Other - Last Name:ACKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:5335 S CAMPBELL AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-2492
Mailing Address - Country:US
Mailing Address - Phone:417-350-1131
Mailing Address - Fax:417-350-1191
Practice Address - Street 1:5335 S CAMPBELL AVE STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65810-2492
Practice Address - Country:US
Practice Address - Phone:417-350-1131
Practice Address - Fax:417-350-1191
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006797111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000015309OtherPTAN
U76778Medicare UPIN
MO000015309OtherPTAN