Basic Information
| Provider Information | |||||||||
| NPI: | 1871961813 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | DY-ANNE | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8126 S SAGINAW AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606171376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7739832536 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9718 S HALSTED ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606281007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732334100 | ||||||||
| FaxNumber: | 7732334055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2015 | ||||||||
| LastUpdateDate: | 09/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 209013009 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.