Provider Demographics
NPI:1730550658
Name:WYANT, CANDICE MARIE (LMP)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:MARIE
Last Name:WYANT
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16919 13TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-7777
Mailing Address - Country:US
Mailing Address - Phone:253-878-6793
Mailing Address - Fax:
Practice Address - Street 1:16919 13TH AVENUE CT E
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-7777
Practice Address - Country:US
Practice Address - Phone:253-878-6793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60503868172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist