Basic Information
Provider Information | |||||||||
NPI: | 1508343161 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEITSCHUH | ||||||||
FirstName: | ANGELINA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GOOD | ||||||||
OtherFirstName: | ANGELINA | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1188 SOUTH STATE ROUTE 157 | ||||||||
Address2: |   | ||||||||
City: | EDWARDSVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 62025 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186925900 | ||||||||
FaxNumber: | 6186925901 | ||||||||
Practice Location | |||||||||
Address1: | 1181 S STATE ROUTE 157 STE 200 | ||||||||
Address2: |   | ||||||||
City: | EDWARDSVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 620253897 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186288211 | ||||||||
FaxNumber: | 6186280883 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2018 | ||||||||
LastUpdateDate: | 08/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209017871 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 209017871 | 01 | IL | IL STATE LICENSE | OTHER |