=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841732773
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE MOYAR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2016
-----------------------------------------------------
Last Update Date | 01/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 475 BROWN BLVD STE 103
-----------------------------------------------------
City | BOURBONNAIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60914-2325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-937-7962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3530 N LAKE SHORE DR APT 7B
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-1894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-403-8444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 209.015115
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------