Basic Information
Provider Information | |||||||||
NPI: | 1437632981 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FROMM | ||||||||
FirstName: | LEIGH | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PMHNP, FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13460 NEW MARKET RD | ||||||||
Address2: |   | ||||||||
City: | RIDGWAY | ||||||||
State: | IL | ||||||||
PostalCode: | 629792506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202381006 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 813 E 4TH ST STE A | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | IN | ||||||||
PostalCode: | 476202012 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124501325 | ||||||||
FaxNumber: | 8128389214 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/11/2018 | ||||||||
LastUpdateDate: | 01/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71009272A | IN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LF0000X | 209018147 | IL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 041418907 | IL | N |   | Nursing Service Providers | Registered Nurse |   | 363LP0808X | 209018147 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.