Provider Demographics
NPI:1104146042
Name:LEONOR, IVELISSE E (FAMILY NURSE PRACTIO)
Entity type:Individual
Prefix:
First Name:IVELISSE
Middle Name:E
Last Name:LEONOR
Suffix:
Gender:F
Credentials:FAMILY NURSE PRACTIO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 NAPIER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2112
Mailing Address - Country:US
Mailing Address - Phone:269-985-4632
Mailing Address - Fax:269-985-4523
Practice Address - Street 1:1234 NAPIER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-985-4632
Practice Address - Fax:269-985-4523
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28162828A163W00000X
IN71003297A363LF0000X
MI4704291709363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000669053OtherANTHEM
IN71003297BOtherCSR
IN200989980Medicaid
IN28162828AOtherRN LICENSE
IN71003297AOtherAPN PRESCRIPTIVE AUTHORITY
MI1104146942Medicaid
IN28162828AOtherRN LICENSE