Basic Information
| Provider Information | |||||||||
| NPI: | 1528629672 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAMMAKER | ||||||||
| FirstName: | KANDACE | ||||||||
| MiddleName: | LUCILLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DIXON | ||||||||
| OtherFirstName: | KANDACE | ||||||||
| OtherMiddleName: | LUCILLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8820 HILLGROVE SOUTHERN RD | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453909019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375645410 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3095 KETTERING BLVD | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372938300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2019 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | TJ551378 | OH | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.