Provider Demographics
NPI:1366900425
Name:TYREE, CANDICE STALLONE
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:STALLONE
Last Name:TYREE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6604 JEFFERSON PAIGE RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-5006
Mailing Address - Country:US
Mailing Address - Phone:318-288-1949
Mailing Address - Fax:
Practice Address - Street 1:6604 JEFFERSON PAIGE RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-5006
Practice Address - Country:US
Practice Address - Phone:318-288-1949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA8099OtherTRANSPORTATION