Provider Demographics
NPI:1760972632
Name:SMITH, CANDACE LEE
Entity Type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:LEE
Last Name:SMITH
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 1:3913 THOUSAND OAKS DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-0717
Mailing Address - Country:US
Mailing Address - Phone:870-243-4348
Mailing Address - Fax:
Practice Address - Street 1:3913 THOUSAND OAKS DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-0717
Practice Address - Country:US
Practice Address - Phone:870-243-4348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4300225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant