Provider Demographics
NPI:1962933085
Name:ONEAL, CANDACE RENEE
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:RENEE
Last Name:ONEAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:RENEE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:51355 PLYMOUTH VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-6371
Mailing Address - Country:US
Mailing Address - Phone:248-506-3698
Mailing Address - Fax:
Practice Address - Street 1:51355 PLYMOUTH VALLEY DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6371
Practice Address - Country:US
Practice Address - Phone:248-506-3698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIO540108734754390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program