Provider Demographics
NPI:1457789687
Name:LELAND, ROSA MARIBEL (APN)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:MARIBEL
Last Name:LELAND
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:ROSA
Other - Middle Name:MARIBEL
Other - Last Name:MOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4101 JOHN DEERE RD
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6790
Mailing Address - Country:US
Mailing Address - Phone:309-757-1905
Mailing Address - Fax:309-757-1906
Practice Address - Street 1:4101 JOHN DEERE RD
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6790
Practice Address - Country:US
Practice Address - Phone:309-757-1905
Practice Address - Fax:309-757-1906
Is Sole Proprietor?:No
Enumeration Date:2013-10-25
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA105946363LF0000X
IL209010841363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209010841OtherIL STATE LICENSE
IAA105946OtherIOWA LICENSE