Provider Demographics
NPI:1255728242
Name:BOON, LEAH R (NNP-BC)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:R
Last Name:BOON
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:R
Other - Last Name:ROE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NNP-BC
Mailing Address - Street 1:201 E MADISON ST STE 328
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5131
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:
Practice Address - Street 1:415 N 9TH ST STE 4W16
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5303
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-757-6844
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-012720363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
IL$$$$$$$$$001Medicaid