Provider Demographics
NPI:1265024632
Name:LEIDECKER, MAUREEN ZIWA
Entity Type:Individual
Prefix:MISS
First Name:MAUREEN
Middle Name:ZIWA
Last Name:LEIDECKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 ROSEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CARPENTERSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60110-1995
Mailing Address - Country:US
Mailing Address - Phone:224-558-6575
Mailing Address - Fax:
Practice Address - Street 1:363 E WACKER DR UNIT 2507
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-5810
Practice Address - Country:US
Practice Address - Phone:224-558-6575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2024-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209025784367500000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty