Provider Demographics
NPI:1831766948
Name:BIRDSONG, LEEANN MARIE
Entity type:Individual
Prefix:
First Name:LEEANN
Middle Name:MARIE
Last Name:BIRDSONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N 12TH ST APT 8
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-3843
Mailing Address - Country:US
Mailing Address - Phone:618-417-2514
Mailing Address - Fax:
Practice Address - Street 1:405 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLE RIVE
Practice Address - State:IL
Practice Address - Zip Code:62810-1228
Practice Address - Country:US
Practice Address - Phone:618-316-1626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider