Healthcare Provider Details

I. General information

NPI: 1508343161
Provider Name (Legal Business Name): ANGELINA M LEITSCHUH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELINA M GOOD

II. Dates (important events)

Enumeration Date: 07/25/2018
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1853 VAUGHN RD
WOOD RIVER IL
62095-1861
US

IV. Provider business mailing address

1853 VAUGHN RD
WOOD RIVER IL
62095-1861
US

V. Phone/Fax

Practice location:
  • Phone: 618-467-1580
  • Fax: 618-467-1581
Mailing address:
  • Phone: 618-467-1580
  • Fax: 618-467-1581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209017871
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209017871
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: