Provider Demographics
NPI:1043277197
Name:COOK, CANDACE K (FNP)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:K
Last Name:COOK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COULTERVILLE MEDICAL CLINIC
Mailing Address - Street 2:203 EAST GRANT
Mailing Address - City:COULTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62237
Mailing Address - Country:US
Mailing Address - Phone:618-758-2331
Mailing Address - Fax:
Practice Address - Street 1:COULTERVILLE MEDICAL CLINIC
Practice Address - Street 2:203 EAST GRANT
Practice Address - City:COULTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62237
Practice Address - Country:US
Practice Address - Phone:618-758-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.004563363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP85814Medicare UPIN