Provider Demographics
NPI:1730455502
Name:FOURNIER, CANDACE LYNN (MT)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:LYNN
Last Name:FOURNIER
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-2915
Mailing Address - Country:US
Mailing Address - Phone:818-224-7600
Mailing Address - Fax:818-224-6400
Practice Address - Street 1:1620 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-2915
Practice Address - Country:US
Practice Address - Phone:818-224-7600
Practice Address - Fax:818-224-6400
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25965225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist