Provider Demographics
NPI:1508343161
Name:LEITSCHUH, ANGELINA M (NP)
Entity Type:Individual
Prefix:
First Name:ANGELINA
Middle Name:M
Last Name:LEITSCHUH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ANGELINA
Other - Middle Name:M
Other - Last Name:GOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1188 SOUTH STATE ROUTE 157
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025
Mailing Address - Country:US
Mailing Address - Phone:618-692-5900
Mailing Address - Fax:618-692-5901
Practice Address - Street 1:1181 S STATE ROUTE 157 STE 200
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3897
Practice Address - Country:US
Practice Address - Phone:618-628-8211
Practice Address - Fax:618-628-0883
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017871363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209017871OtherIL STATE LICENSE