Provider Demographics
NPI:1447846506
Name:HILLIS, KANDANCE (PTA)
Entity type:Individual
Prefix:
First Name:KANDANCE
Middle Name:
Last Name:HILLIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2760 N GRANDVIEW AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-6953
Mailing Address - Country:US
Mailing Address - Phone:432-552-7034
Mailing Address - Fax:
Practice Address - Street 1:2760 N GRANDVIEW AVE STE A
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-6953
Practice Address - Country:US
Practice Address - Phone:432-552-7034
Practice Address - Fax:432-552-7165
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2156622208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation