Provider Demographics
NPI:1447929914
Name:KUDLA, CANDACE CRYSTAL (APRN)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:CRYSTAL
Last Name:KUDLA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S REDBUD LN
Mailing Address - Street 2:
Mailing Address - City:FLANAGAN
Mailing Address - State:IL
Mailing Address - Zip Code:61740-9111
Mailing Address - Country:US
Mailing Address - Phone:815-257-1237
Mailing Address - Fax:
Practice Address - Street 1:1506 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9674
Practice Address - Country:US
Practice Address - Phone:815-844-6123
Practice Address - Fax:815-844-3897
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023553363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care