Provider Demographics
NPI:1194889014
Name:DALTON, CANDIE NAOMI (PT)
Entity type:Individual
Prefix:MS
First Name:CANDIE
Middle Name:NAOMI
Last Name:DALTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:CANDIE
Other - Middle Name:NAOMI
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:39 CORNETT CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:ANNVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40402-9712
Mailing Address - Country:US
Mailing Address - Phone:606-364-2665
Mailing Address - Fax:
Practice Address - Street 1:69 STATE ROAD 3444
Practice Address - Street 2:
Practice Address - City:ANNVILLE
Practice Address - State:KY
Practice Address - Zip Code:40402
Practice Address - Country:US
Practice Address - Phone:606-364-2260
Practice Address - Fax:606-364-5187
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY003343225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0980502Medicare ID - Type Unspecified