Provider Demographics
NPI:1790035202
Name:MEINARDUS, CANDACE NICOLE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:NICOLE
Last Name:MEINARDUS
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 1:1404 KEYSTONE LOOP
Mailing Address - Street 2:
Mailing Address - City:MULBERRY
Mailing Address - State:AR
Mailing Address - Zip Code:72947-9129
Mailing Address - Country:US
Mailing Address - Phone:479-739-4604
Mailing Address - Fax:
Practice Address - Street 1:1404 KEYSTONE LOOP
Practice Address - Street 2:
Practice Address - City:MULBERRY
Practice Address - State:AR
Practice Address - Zip Code:72947-9129
Practice Address - Country:US
Practice Address - Phone:479-739-4604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2496225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant