Healthcare Provider Details

I. General information

NPI: 1255682670
Provider Name (Legal Business Name): MORGAN TIFFANY LESIEWICZ APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MORGAN TIFFANY DELFS APN

II. Dates (important events)

Enumeration Date: 09/25/2012
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 W PETERSON AVE
CHICAGO IL
60659-4277
US

IV. Provider business mailing address

2112 W PETERSON AVE
CHICAGO IL
60659-4277
US

V. Phone/Fax

Practice location:
  • Phone: 773-761-3001
  • Fax:
Mailing address:
  • Phone: 773-761-3001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041376616
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209009831
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: