Basic Information
| Provider Information | |||||||||
| NPI: | 1427328798 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LESLEY GLENN | ||||||||
| FirstName: | MEGAN | ||||||||
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| Credential: | P.A.-C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1820 SALTONSTALL DR | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617619354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302478497 | ||||||||
| FaxNumber: | 3096248820 | ||||||||
| Practice Location | |||||||||
| Address1: | 3024 E EMPIRE ST STE EANDF | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617045402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094513376 | ||||||||
| FaxNumber: | 3094523376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2012 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085.004236 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.