Provider Demographics
NPI:1932636339
Name:LESLIE MCILVRIED APRN BC LLC
Entity Type:Organization
Organization Name:LESLIE MCILVRIED APRN BC LLC
Other - Org Name:LESLIE MCILVRIED APRN BC LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCILVRIED
Authorized Official - Suffix:
Authorized Official - Credentials:APRN BC
Authorized Official - Phone:630-983-8920
Mailing Address - Street 1:1755 PARK ST
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-4861
Mailing Address - Country:US
Mailing Address - Phone:630-983-8920
Mailing Address - Fax:630-983-4839
Practice Address - Street 1:1755 PARK ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-4861
Practice Address - Country:US
Practice Address - Phone:630-983-8920
Practice Address - Fax:630-983-4839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041410686363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1225098445OtherNPI TYPE 1