Provider Demographics
NPI:1336780030
Name:GINGLES, CANDICE RENE
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:RENE
Last Name:GINGLES
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 1:7499 OAK ST NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-5443
Mailing Address - Country:US
Mailing Address - Phone:407-927-4901
Mailing Address - Fax:
Practice Address - Street 1:17470 BROOKSIDE TRACE CT
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-6201
Practice Address - Country:US
Practice Address - Phone:813-600-5994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17253224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant