Individual
LESLIE M. CARMACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
A.P.N.
Contact information
Practice address
1701 E COLLEGE AVE, BLOOMINGTON, IL 61704-2101
(309) 664-3800
(309) 664-3461
Mailing address
1701 E COLLEGE AVE, BLOOMINGTON, IL 61704-2101
(309) 664-3800
(309) 664-3461
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
209-007212
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
IL2613
MEDICARE GROUP PTAN
IL
01
—
IL2613053
INDIVIDUAL MEDICARE PTAN
IL
Enumeration date
08/25/2008
Last updated
10/06/2020
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