Healthcare Provider Details

I. General information

NPI: 1326317512
Provider Name (Legal Business Name): STEPHANIE LEOPOLD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S CALIFORNIA AVE
CHICAGO IL
60608-1732
US

IV. Provider business mailing address

360 W ILLINOIS ST APT 5F
CHICAGO IL
60654-3658
US

V. Phone/Fax

Practice location:
  • Phone: 773-257-6850
  • Fax: 773-257-6050
Mailing address:
  • Phone: 217-417-5963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.009194
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: