Healthcare Provider Details

I. General information

NPI: 1982901153
Provider Name (Legal Business Name): CANDY L WIDMER LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2011
Last Update Date: 02/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 S PERRY ST
SPOKANE WA
99202-3465
US

IV. Provider business mailing address

214 N BANNEN RD
SPOKANE VALLEY WA
99216-2273
US

V. Phone/Fax

Practice location:
  • Phone: 509-434-9267
  • Fax:
Mailing address:
  • Phone: 509-892-6936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 60188231
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: