Healthcare Provider Details

I. General information

NPI: 1326191636
Provider Name (Legal Business Name): GWEN M MARKHAM CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 N WALL ST
KANKAKEE IL
60901-2901
US

IV. Provider business mailing address

PO BOX 13749
PHILADELPHIA PA
19101-3749
US

V. Phone/Fax

Practice location:
  • Phone: 815-993-1671
  • Fax: 815-936-6971
Mailing address:
  • Phone: 855-447-2240
  • Fax: 302-733-0854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041-286365
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209-003239
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: