Provider Demographics
NPI:1700644234
Name:STANDAGE, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:STANDAGE
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 1:5620 JAY DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-4644
Mailing Address - Country:US
Mailing Address - Phone:815-861-2148
Mailing Address - Fax:
Practice Address - Street 1:5620 JAY DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-4644
Practice Address - Country:US
Practice Address - Phone:815-861-2148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program