Provider Demographics
NPI:1679002877
Name:HEARNS, KANDICE MONIQUE
Entity Type:Individual
Prefix:
First Name:KANDICE
Middle Name:MONIQUE
Last Name:HEARNS
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 1:503 CHURCHILL DR
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7321
Mailing Address - Country:US
Mailing Address - Phone:321-684-8328
Mailing Address - Fax:
Practice Address - Street 1:175 NE VILLA NUEVA AVE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907
Practice Address - Country:US
Practice Address - Phone:321-952-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24849225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant