Basic Information
| Provider Information | |||||||||
| NPI: | 1861689143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LESKO | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CROWE | ||||||||
| OtherFirstName: | CAROL | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 632 E CHAIN OF ROCKS RD | ||||||||
| Address2: | |||||||||
| City: | GRANITE CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620402805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185673566 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 270 MAPLE SUMMIT RD | ||||||||
| Address2: | |||||||||
| City: | JERSEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620522004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184982273 | ||||||||
| FaxNumber: | 6186397997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 01/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 18209 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LW0102X | 209003178 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 118209 | 05 | MO | MEDICAID | 209003178 | 05 | IL | MEDICAID |