Provider Demographics
NPI:1003956871
Name:LEGENDRE, COURTNEY BETH (FNP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:BETH
Last Name:LEGENDRE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:BETH
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN,BC
Mailing Address - Street 1:545 VALLEY VIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6138
Mailing Address - Country:US
Mailing Address - Phone:309-762-5560
Mailing Address - Fax:309-762-7351
Practice Address - Street 1:545 VALLEY VIEW DRIVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6138
Practice Address - Country:US
Practice Address - Phone:309-762-5560
Practice Address - Fax:309-762-7351
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005686363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209005686OtherILLINOIS LICENSE
ILF400264097Medicare PIN