Provider Demographics
NPI:1225219538
Name:NEGLEY-TACKETT, CANDICE (AUD)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:NEGLEY-TACKETT
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5317
Mailing Address - Country:US
Mailing Address - Phone:269-324-0301
Mailing Address - Fax:269-324-2387
Practice Address - Street 1:1111 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5317
Practice Address - Country:US
Practice Address - Phone:269-324-0301
Practice Address - Fax:269-324-2387
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000484237600000X, 237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1601000484OtherMI STATE LICENSE NUMBER