Healthcare Provider Details

I. General information

NPI: 1306661293
Provider Name (Legal Business Name): CANDICE ANNE HENDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 RANGELEY AVE
DAYTON OH
45403-1617
US

IV. Provider business mailing address

1503 RANGELEY AVE
DAYTON OH
45403-1617
US

V. Phone/Fax

Practice location:
  • Phone: 419-283-6822
  • Fax:
Mailing address:
  • Phone: 419-283-6822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: