Basic Information
| Provider Information | |||||||||
| NPI: | 1942531090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAGGART | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 HEALTH CENTER DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172386055 | ||||||||
| FaxNumber: | 2172582216 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 HEALTH CENTER DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172584030 | ||||||||
| FaxNumber: | 2172582353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2010 | ||||||||
| LastUpdateDate: | 01/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209008018 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.