Provider Demographics
NPI:1073760716
Name:CARMACK, LESLIE M (APN)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:M
Last Name:CARMACK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2101
Mailing Address - Country:US
Mailing Address - Phone:309-664-3800
Mailing Address - Fax:309-664-3461
Practice Address - Street 1:1701 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2101
Practice Address - Country:US
Practice Address - Phone:309-664-3800
Practice Address - Fax:309-664-3461
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-007212363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2613OtherMEDICARE GROUP PTAN
ILIL2613053OtherINDIVIDUAL MEDICARE PTAN