Healthcare Provider Details

I. General information

NPI: 1427328798
Provider Name (Legal Business Name): MEGAN LESLEY GLENN P.A.-C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2012
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3024 E EMPIRE ST STE EANDF
BLOOMINGTON IL
61704-5402
US

IV. Provider business mailing address

1820 SALTONSTALL DR
NORMAL IL
61761-9354
US

V. Phone/Fax

Practice location:
  • Phone: 309-451-3376
  • Fax: 309-452-3376
Mailing address:
  • Phone: 630-247-8497
  • Fax: 309-624-8820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.004236
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: