Provider Demographics
NPI:1649515685
Name:KANDIKO, PATTY JEAN (CNM)
Entity type:Individual
Prefix:
First Name:PATTY
Middle Name:JEAN
Last Name:KANDIKO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2241 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-7423
Mailing Address - Country:US
Mailing Address - Phone:970-549-1711
Mailing Address - Fax:970-314-2633
Practice Address - Street 1:2241 N 7TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-7423
Practice Address - Country:US
Practice Address - Phone:970-549-1711
Practice Address - Fax:970-314-2633
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0990542176B00000X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO330749YXN7OtherMEDICARE ID
CO62975862Medicaid