Healthcare Provider Details

I. General information

NPI: 1760630925
Provider Name (Legal Business Name): KATHLEEN A LEINEN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2008
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 S 1ST ST STE 100
FAIRBURY IL
61739-1509
US

IV. Provider business mailing address

106 S 1ST ST STE 100
FAIRBURY IL
61739-1509
US

V. Phone/Fax

Practice location:
  • Phone: 815-692-2308
  • Fax: 815-692-3278
Mailing address:
  • Phone: 815-692-2308
  • Fax: 815-692-3278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036121354
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberN0919
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: