Provider Demographics
NPI:1912344003
Name:RICHARDSON, CANDIE DAVIS (LPN)
Entity type:Individual
Prefix:MRS
First Name:CANDIE
Middle Name:DAVIS
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1748 IRON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-5294
Mailing Address - Country:US
Mailing Address - Phone:850-539-3865
Mailing Address - Fax:850-539-0736
Practice Address - Street 1:1748 IRON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:FL
Practice Address - Zip Code:32333-5294
Practice Address - Country:US
Practice Address - Phone:850-539-3865
Practice Address - Fax:850-539-0736
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6905367311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home