Provider Demographics
NPI:1619403623
Name:MCCLELLAND-SANDRIDGE, LEONORA
Entity Type:Individual
Prefix:
First Name:LEONORA
Middle Name:
Last Name:MCCLELLAND-SANDRIDGE
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 1:14504 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-1828
Mailing Address - Country:US
Mailing Address - Phone:708-339-2490
Mailing Address - Fax:
Practice Address - Street 1:14504 GREEN ST
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-1828
Practice Address - Country:US
Practice Address - Phone:708-339-2490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILS536-5335-6602251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health