Individual
IVELISSE E LEONOR
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FAMILY NURSE PRACTIO
Contact information
Practice address
1234 NAPIER AVE, SAINT JOSEPH, MI 49085
(269) 985-4632
(269) 985-4523
Mailing address
1234 NAPIER AVE, SAINT JOSEPH, MI 49085-2112
(269) 985-4632
(269) 985-4523
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
28162828A
IN
363LF0000X
Family Nurse Practitioner
Primary
4704291709
MI
363LF0000X
Family Nurse Practitioner
71003297A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000669053
ANTHEM
IN
05
—
1104146942
—
MI
05
—
200989980
—
IN
01
—
28162828A
RN LICENSE
IN
01
—
71003297A
APN PRESCRIPTIVE AUTHORITY
IN
01
—
71003297B
CSR
IN
Enumeration date
06/02/2010
Last updated
08/01/2018
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