Individual
DIETRA LEIGH ANGELLY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
FNP-C
Contact information
Practice address
3411 PROFESSIONAL PARK DR, MARION, IL 62959-6394
(618) 969-8630
(618) 993-1421
Mailing address
408 LINCOLN DR STE B, HERRIN, IL 62948-3790
(618) 351-4980
(618) 993-8418
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
209018044
IL
363LF0000X
Family Nurse Practitioner
209018044
IL
Other
Enumeration date
10/11/2018
Last updated
04/08/2024
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