Provider Demographics
NPI:1841732773
Name:MOYAR, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MOYAR
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 1:3530 N LAKE SHORE DR
Mailing Address - Street 2:APT 7B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-1894
Mailing Address - Country:US
Mailing Address - Phone:708-403-8444
Mailing Address - Fax:
Practice Address - Street 1:475 BROWN BLVD STE 103
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2325
Practice Address - Country:US
Practice Address - Phone:815-937-7962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015115363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care