Provider Demographics
NPI:1265763163
Name:MAHANEY CALDWELL, GRETCHEN L (APN)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:L
Last Name:MAHANEY CALDWELL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:619 E MASON ST STE 4P57
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-1034
Mailing Address - Country:US
Mailing Address - Phone:217-788-0706
Mailing Address - Fax:217-525-2535
Practice Address - Street 1:619 E MASON ST STE 4P57
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1034
Practice Address - Country:US
Practice Address - Phone:217-788-0706
Practice Address - Fax:217-525-2535
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-18
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.007736207RI0011X
IL209007736363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology