Provider Demographics
NPI:1265999361
Name:KIDD, CANDACE
Entity type:Individual
Prefix:MS
First Name:CANDACE
Middle Name:
Last Name: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 1:5366 SANDUSKY RD
Mailing Address - Street 2:
Mailing Address - City:PECK
Mailing Address - State:MI
Mailing Address - Zip Code:48466-9791
Mailing Address - Country:US
Mailing Address - Phone:810-378-5595
Mailing Address - Fax:
Practice Address - Street 1:5366 SANDUSKY RD
Practice Address - Street 2:
Practice Address - City:PECK
Practice Address - State:MI
Practice Address - Zip Code:48466-9791
Practice Address - Country:US
Practice Address - Phone:810-378-5595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI470308191164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse