Provider Demographics
NPI:1710331947
Name:CANDREVA, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:CANDREVA
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 1:9629 ASHLEY LAKE CT APT F
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1715
Mailing Address - Country:US
Mailing Address - Phone:828-640-2213
Mailing Address - Fax:
Practice Address - Street 1:1010 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28134-7567
Practice Address - Country:US
Practice Address - Phone:704-889-0169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5702225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant