Provider Demographics
NPI:1114549219
Name:POWERS, KANDACE
Entity Type:Individual
Prefix:
First Name:KANDACE
Middle Name:
Last Name:POWERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4200
Mailing Address - Country:US
Mailing Address - Phone:630-208-4060
Mailing Address - Fax:630-208-4401
Practice Address - Street 1:300 RANDALL RD FL 2
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4200
Practice Address - Country:US
Practice Address - Phone:630-208-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021568367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered