Provider Demographics
NPI:1881494086
Name:FREY, CANDYCE
Entity type:Individual
Prefix:
First Name:CANDYCE
Middle Name:
Last Name:FREY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 TALON DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1848
Mailing Address - Country:US
Mailing Address - Phone:618-628-8211
Mailing Address - Fax:618-628-0883
Practice Address - Street 1:4414 W CENTER DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5932
Practice Address - Country:US
Practice Address - Phone:618-628-8211
Practice Address - Fax:618-628-0883
Is Sole Proprietor?:No
Enumeration Date:2025-03-17
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.031860207R00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine