Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 36062823 | IL |
NPI | 1013004928 |
---|---|
Provider Name | Karen Leone |
First Address | Great Lakes, IL 60088-2833 |
Second Address | Great Lakes, IL 60088-2833 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D15283 | (02) |