Basic Information
| Provider Information | |||||||||
| NPI: | 1447929914 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUDLA | ||||||||
| FirstName: | CANDACE | ||||||||
| MiddleName: | CRYSTAL | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 S REDBUD LN | ||||||||
| Address2: | |||||||||
| City: | FLANAGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617409111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152571237 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1506 W REYNOLDS ST | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617649674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158446123 | ||||||||
| FaxNumber: | 8158443897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2021 | ||||||||
| LastUpdateDate: | 09/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 209023553 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.