Healthcare Provider Details

I. General information

NPI: 1760981179
Provider Name (Legal Business Name): CANDICE LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 02/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FRANKLIN ST
HAMPTON VA
23669-3568
US

IV. Provider business mailing address

16 SWEET GUM PL
HAMPTON VA
23666-6814
US

V. Phone/Fax

Practice location:
  • Phone: 757-727-2000
  • Fax:
Mailing address:
  • Phone: 757-602-6094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202006574
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: