Provider Demographics
NPI:1225098445
Name:MCILVRIED, LESLIE S (NP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:S
Last Name:MCILVRIED
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 STEEPLECHASE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-4705
Mailing Address - Country:US
Mailing Address - Phone:508-631-5000
Mailing Address - Fax:
Practice Address - Street 1:1755 PARK ST
Practice Address - Street 2:SUITE #300
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-4861
Practice Address - Country:US
Practice Address - Phone:630-416-6056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA242197363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0367630Medicaid
MAC434OtherHARVARD PILGRIM
MANP3266OtherBLUE CROSS
MAC434OtherHARVARD PILGRIM
MAP31641Medicare UPIN