Provider Demographics
NPI:1902552102
Name:GONNEVILLE, LEAH ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:ELIZABETH
Last Name:GONNEVILLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1642 N MARSHFIELD AVE APT 2R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1445
Mailing Address - Country:US
Mailing Address - Phone:207-436-5078
Mailing Address - Fax:
Practice Address - Street 1:1642 N MARSHFIELD AVE APT 2R
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1445
Practice Address - Country:US
Practice Address - Phone:207-436-5078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008942363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant