Provider Demographics
NPI:1548732373
Name:MEDDERS, LESLY KAY (FNP)
Entity type:Individual
Prefix:
First Name:LESLY
Middle Name:KAY
Last Name:MEDDERS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 HIGHLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-5682
Mailing Address - Country:US
Mailing Address - Phone:727-475-0830
Mailing Address - Fax:
Practice Address - Street 1:3005 HIGHLAND PKWY
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-5682
Practice Address - Country:US
Practice Address - Phone:727-475-0830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN267559363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily