Provider Demographics
NPI:1265771943
Name:LASSITER, CANDACE JENELL CROSS
Entity type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:JENELL CROSS
Last Name:LASSITER
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 1:4 MOUNTAIN ASHE PL
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2175
Mailing Address - Country:US
Mailing Address - Phone:757-825-1660
Mailing Address - Fax:
Practice Address - Street 1:4 MOUNTAIN ASHE PL
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2175
Practice Address - Country:US
Practice Address - Phone:757-825-1660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602453225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant