Provider Demographics
NPI:1013193457
Name:ANTONELLI, LESLIE M (MSN, RN)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:M
Last Name:ANTONELLI
Suffix:
Gender:F
Credentials:MSN, RN
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:M
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, RN
Mailing Address - Street 1:8111 TOWNSHIP LINE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2479
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8111 TOWNSHIP LINE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2479
Practice Address - Country:US
Practice Address - Phone:317-415-7921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28154154A163W00000X
IN71002959A363LP0200X, 363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200953450Medicaid