Provider Demographics
NPI:1740651637
Name:CORNIUK, CANDIE SUE (LMP)
Entity type:Individual
Prefix:MRS
First Name:CANDIE
Middle Name:SUE
Last Name:CORNIUK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:CANDIE
Other - Middle Name:SUE
Other - Last Name:CLINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:15316 CARTER CT SE
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-8575
Mailing Address - Country:US
Mailing Address - Phone:253-273-9062
Mailing Address - Fax:
Practice Address - Street 1:715 E YELM AVE
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-8734
Practice Address - Country:US
Practice Address - Phone:360-458-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-17
Last Update Date:2015-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60580235225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist