Provider Demographics
NPI:1801439161
Name:STANDIFORD, KACY MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KACY
Middle Name:MARIE
Last Name:STANDIFORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 N MELVIN ST
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-1477
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:GIBSON CITY
Practice Address - State:IL
Practice Address - Zip Code:60936-2004
Practice Address - Country:US
Practice Address - Phone:217-784-4340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007378207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370647938OtherMOLINA NUMBER