Individual
MS. CANDICE LEA VAN IDERSTINE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.T.
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
14653
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0001
BC/BS OF DC GROUPG719
DC
01
—
2142926
MAMSI PROVIDER NUMBER
MD
01
—
3346568
AETNA HMO PROVIDER #
MD
01
—
7082461
AETNA HMO PROVIDER NUMBER
MD
01
—
KFK1
BC/BS OF MARYLAND GROUP 6
MD
Enumeration date
09/12/2006
Last updated
07/08/2007
Update your record
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