Provider Demographics
NPI:1902496342
Name:WILSON, KANDYCE IVORY
Entity Type:Individual
Prefix:
First Name:KANDYCE
Middle Name:IVORY
Last Name:WILSON
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 1:1692 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-2443
Mailing Address - Country:US
Mailing Address - Phone:216-760-3563
Mailing Address - Fax:
Practice Address - Street 1:1692 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-2443
Practice Address - Country:US
Practice Address - Phone:216-760-3563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist