Provider Demographics
NPI:1609972645
Name:GREMLEY, CANDICE N (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:N
Last Name:GREMLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:CANDICE
Other - Middle Name:N
Other - Last Name:BUDNIESKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 W COURT ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3661
Mailing Address - Country:US
Mailing Address - Phone:815-937-2100
Mailing Address - Fax:
Practice Address - Street 1:500 W COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3661
Practice Address - Country:US
Practice Address - Phone:815-937-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
4622394OtherBLUE CROSS
4622394OtherBLUE CROSS
208614Medicare PIN
P00395675Medicare PIN
K37441Medicare PIN