Healthcare Provider Details

I. General information

NPI: 1013193457
Provider Name (Legal Business Name): LESLIE M ANTONELLI MSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LESLIE M PETERS MSN, RN

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 W STONES CROSSING RD STE 330
GREENWOOD IN
46143-8558
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 317-887-6060
  • Fax: 317-859-5944
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number71002959A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71002959A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28154154A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: