Provider Demographics
NPI:1790098119
Name:LUCAS-CLAY, LEIGH (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:LEIGH
Middle Name:
Last Name:LUCAS-CLAY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 N STATE ROUTE 91
Mailing Address - Street 2:SUITE 250
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-9541
Mailing Address - Country:US
Mailing Address - Phone:309-692-5393
Mailing Address - Fax:309-692-2538
Practice Address - Street 1:8600 N STATE ROUTE 91
Practice Address - Street 2:SUITE 250
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-9541
Practice Address - Country:US
Practice Address - Phone:309-692-5393
Practice Address - Fax:309-692-2538
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008207367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicaid