Healthcare Provider Details

I. General information

NPI: 1942640784
Provider Name (Legal Business Name): LAUREN M LEIGHTON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN M KIRSCH PA-C

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 08/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST STE 18-250
CHICAGO IL
60611-5980
US

IV. Provider business mailing address

490 OLIVE ST
ELMHURST IL
60126
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-8624
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.004630
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: