Healthcare Provider Details

I. General information

NPI: 1699528596
Provider Name (Legal Business Name): LESLIE ANN FERMIN DEPAYSO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2024
Last Update Date: 04/09/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W PARK ST
URBANA IL
61801-2501
US

IV. Provider business mailing address

1505 MONTGOMERY ST
URBANA IL
61802-4742
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3610
  • Fax:
Mailing address:
  • Phone: 561-990-9587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.028491
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: