Healthcare Provider Details

I. General information

NPI: 1376196006
Provider Name (Legal Business Name): BRENNA SELENA LEIKER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24600 W 127TH ST
PLAINFIELD IL
60585-9507
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 630-961-7485
  • Fax: 815-731-4406
Mailing address:
  • Phone: 847-570-2114
  • Fax: 847-570-1223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085007116
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085007116
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: