Healthcare Provider Details

I. General information

NPI: 1548309024
Provider Name (Legal Business Name): CANDACE F. ZICKLER CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PLZ DEVELOPMENTAL PEDIATRICS
DAYTON OH
45404-1898
US

IV. Provider business mailing address

3372 RIDGEWAY RD
KETTERING OH
45419-1120
US

V. Phone/Fax

Practice location:
  • Phone: 937-641-4000
  • Fax: 937-641-5076
Mailing address:
  • Phone: 937-299-5014
  • Fax: 937-299-5014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN-264091
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: