Provider Demographics
NPI:1811969892
Name:SEALES, LESA RENEE' (AA-C)
Entity type:Individual
Prefix:MRS
First Name:LESA
Middle Name:RENEE'
Last Name:SEALES
Suffix:
Gender:F
Credentials:AA-C
Other - Prefix:MISS
Other - First Name:LESA
Other - Middle Name:RENEE'
Other - Last Name:STOECKLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA-C
Mailing Address - Street 1:3215 EXECUTIVE PARK DR.
Mailing Address - Street 2:HSHS MEDICAL GROUP
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703
Mailing Address - Country:US
Mailing Address - Phone:618-234-2120
Mailing Address - Fax:618-641-5410
Practice Address - Street 1:211 S. 3RD ST.
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:618-641-5410
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009028903367H00000X
161D367H00000X
ILAA NOT LIC. BY STATE163WP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No163WP0000XNursing Service ProvidersRegistered NursePain Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK26873Medicare ID - Type Unspecified