Provider Demographics
NPI:1659790350
Name:SPANGLER, KEVIN (APN)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:SPANGLER
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 E WAR MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61616-7757
Mailing Address - Country:US
Mailing Address - Phone:309-685-4411
Mailing Address - Fax:
Practice Address - Street 1:1120 E WAR MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616
Practice Address - Country:US
Practice Address - Phone:309-685-4411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017904363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209017904OtherLICENSE