Provider Demographics
NPI:1962181115
Name:MOONEYHAM, KANDISE ROSE MARIE
Entity type:Individual
Prefix:
First Name:KANDISE
Middle Name:ROSE MARIE
Last Name:MOONEYHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KANDISE
Other - Middle Name:ROSE MARIE
Other - Last Name:BELISLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:28594 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1285
Mailing Address - Country:US
Mailing Address - Phone:630-859-6800
Mailing Address - Fax:
Practice Address - Street 1:80 TEMPLETON DR
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-7000
Practice Address - Country:US
Practice Address - Phone:630-554-3456
Practice Address - Fax:630-551-2970
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-14
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209028373363LF0000X
IL041452140163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse