Provider Demographics
NPI:1720575806
Name:LESLIE WILLIAMS APN LLC
Entity Type:Organization
Organization Name:LESLIE WILLIAMS APN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:618-918-2115
Mailing Address - Street 1:1998 STATE ROUTE 161
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-6754
Mailing Address - Country:US
Mailing Address - Phone:618-339-2114
Mailing Address - Fax:918-918-2142
Practice Address - Street 1:1007 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3001
Practice Address - Country:US
Practice Address - Phone:618-918-2115
Practice Address - Fax:618-918-2142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007351363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209007351Medicaid