Provider Demographics
NPI:1306663943
Name:LEICK, EMILY ANN (NP)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ANN
Last Name:LEICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2797 CENTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61102-3705
Mailing Address - Country:US
Mailing Address - Phone:815-262-2744
Mailing Address - Fax:
Practice Address - Street 1:1401 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2315
Practice Address - Country:US
Practice Address - Phone:779-696-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.030658363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care