Provider Demographics
NPI:1477191336
Name:GRAVESEN, LEAH
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:GRAVESEN
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 1:106 KAREN DR
Mailing Address - Street 2:
Mailing Address - City:DWIGHT
Mailing Address - State:IL
Mailing Address - Zip Code:60420-1600
Mailing Address - Country:US
Mailing Address - Phone:815-257-5324
Mailing Address - Fax:
Practice Address - Street 1:311 S OTTER CREEK RD
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-3117
Practice Address - Country:US
Practice Address - Phone:815-257-5324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020593363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily