Provider Demographics
NPI:1124503602
Name:APHAIVONG, CANDICE MICHELLE PIELAGO (FNP-BC)
Entity type:Individual
Prefix:
First Name:CANDICE MICHELLE
Middle Name:PIELAGO
Last Name:APHAIVONG
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 EVERGREEN LN
Mailing Address - Street 2:
Mailing Address - City:PINGREE GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60140-9103
Mailing Address - Country:US
Mailing Address - Phone:773-600-2005
Mailing Address - Fax:
Practice Address - Street 1:370 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-3843
Practice Address - Country:US
Practice Address - Phone:847-608-1344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018293363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily