Provider Demographics
NPI:1093172132
Name:LEEBERG, KENNETH C (CRNA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:C
Last Name:LEEBERG
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23654 SPRINGS CT UNIT 119
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-2243
Mailing Address - Country:US
Mailing Address - Phone:630-567-2132
Mailing Address - Fax:
Practice Address - Street 1:19624 GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2077
Practice Address - Country:US
Practice Address - Phone:708-798-5838
Practice Address - Fax:708-798-5865
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013780367500000X
IL041395579367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered