Basic Information
| Provider Information | |||||||||
| NPI: | 1811463854 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUDAK | ||||||||
| FirstName: | CANDICE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4636 LAKES EDGE APT 23 | ||||||||
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| City: | WEST CHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450698591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198691553 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 N JOHN R WOODEN DR | ||||||||
| Address2: | |||||||||
| City: | WEST LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479072117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654943245 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2018 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.