Provider Demographics
NPI:1760290209
Name:TILLMAN, CANDICE (MA106596)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:MA106596
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11031 NE 78TH TER
Mailing Address - Street 2:
Mailing Address - City:BRONSON
Mailing Address - State:FL
Mailing Address - Zip Code:32621-3350
Mailing Address - Country:US
Mailing Address - Phone:360-359-5235
Mailing Address - Fax:
Practice Address - Street 1:11031 NE 78TH TER
Practice Address - Street 2:
Practice Address - City:BRONSON
Practice Address - State:FL
Practice Address - Zip Code:32621-3350
Practice Address - Country:US
Practice Address - Phone:360-359-5235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA106596225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist