Provider Demographics
NPI:1730529025
Name:MELVIN, CANDICE SHANIECE
Entity type:Individual
Prefix:MISS
First Name:CANDICE
Middle Name:SHANIECE
Last Name:MELVIN
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 1:610 BROADWAY
Mailing Address - Street 2:BOX 237
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-5130
Mailing Address - Country:US
Mailing Address - Phone:919-333-2575
Mailing Address - Fax:845-565-4170
Practice Address - Street 1:182 LIBERTY ST
Practice Address - Street 2:APT 1
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-4912
Practice Address - Country:US
Practice Address - Phone:919-333-2575
Practice Address - Fax:845-565-4170
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY313167164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse