Healthcare Provider Details

I. General information

NPI: 1679277578
Provider Name (Legal Business Name): LEANNE BEASLEY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5213 GODFREY RD STE 110
GODFREY IL
62035-2510
US

IV. Provider business mailing address

PO BOX 959203
SAINT LOUIS MO
63195-9203
US

V. Phone/Fax

Practice location:
  • Phone: 618-619-3330
  • Fax: 618-619-3385
Mailing address:
  • Phone: 618-619-3330
  • Fax: 618-619-3385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.082577
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: