Provider Demographics
NPI:1902371313
Name:ANGELLY, DIETRA LEIGH (FNP-C)
Entity Type:Individual
Prefix:
First Name:DIETRA
Middle Name:LEIGH
Last Name:ANGELLY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 LINCOLN DR STE B
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3790
Mailing Address - Country:US
Mailing Address - Phone:618-351-4980
Mailing Address - Fax:618-993-8418
Practice Address - Street 1:3411 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-6394
Practice Address - Country:US
Practice Address - Phone:618-969-8630
Practice Address - Fax:618-993-1421
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-11
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018044363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily