Healthcare Provider Details

I. General information

NPI: 1811529464
Provider Name (Legal Business Name): DANIELLE MARIE LEACHMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DANIELLE MARIE LACOUR

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 03/15/2024
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4709 GOLF RD STE 300
SKOKIE IL
60076-1233
US

IV. Provider business mailing address

4709 GOLF RD STE 300
SKOKIE IL
60076-1233
US

V. Phone/Fax

Practice location:
  • Phone: 847-869-7233
  • Fax: 847-869-9461
Mailing address:
  • Phone: 847-869-7233
  • Fax: 847-869-9461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085.008450
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: