Provider Demographics
NPI:1891347068
Name:MIDDLETON-KIDD, CANDACE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:MIDDLETON-KIDD
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 1:500 AMALFI LOOP APT 484
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-8086
Mailing Address - Country:US
Mailing Address - Phone:901-672-2173
Mailing Address - Fax:
Practice Address - Street 1:8380 CENTER DR STE E
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2952
Practice Address - Country:US
Practice Address - Phone:619-466-6077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225B00000X
CA36837227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered
No225B00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPulmonary Function Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000OtherCCS