Provider Demographics
NPI:1730589409
Name:JOHNSTON, CANDICE SUZANNE (PTA)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:SUZANNE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:SUZANNE
Other - Last Name:MEEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:PO BOX 450
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38485-0450
Mailing Address - Country:US
Mailing Address - Phone:931-722-2778
Mailing Address - Fax:931-722-7569
Practice Address - Street 1:514 S HIGH ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:TN
Practice Address - Zip Code:38485-2615
Practice Address - Country:US
Practice Address - Phone:931-722-2778
Practice Address - Fax:931-722-7569
Is Sole Proprietor?:No
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5727225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant