Healthcare Provider Details

I. General information

NPI: 1902371313
Provider Name (Legal Business Name): DIETRA LEIGH ANGELLY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3411 PROFESSIONAL PARK DR
MARION IL
62959-6394
US

IV. Provider business mailing address

408 LINCOLN DR STE B
HERRIN IL
62948-3790
US

V. Phone/Fax

Practice location:
  • Phone: 618-969-8630
  • Fax: 618-993-1421
Mailing address:
  • Phone: 618-351-4980
  • Fax: 618-993-8418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209018044
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209018044
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: