Healthcare Provider Details

I. General information

NPI: 1346788627
Provider Name (Legal Business Name): STEPHANIE NICOLE LEVERENTZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE N PEASE PA-C

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 S RANDALL RD
ALGONQUIN IL
60102-5944
US

IV. Provider business mailing address

PO BOX 735263
CHICAGO IL
60673-5263
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-9491
  • Fax: 815-381-7498
Mailing address:
  • Phone: 815-398-9491
  • Fax: 815-381-7498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006124
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: