Provider Demographics
NPI:1013193457
Name:ANTONELLI, LESLIE M (MSN, RN)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:M
Last Name:ANTONELLI
Suffix:
Gender:F
Credentials:MSN, RN
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:M
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, RN
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1703 W STONES CROSSING RD STE 330
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-8558
Practice Address - Country:US
Practice Address - Phone:317-887-6060
Practice Address - Fax:317-859-5944
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28154154A163W00000X
IN71002959A363LN0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200953450Medicaid