Provider Demographics
NPI:1760630925
Name:LEINEN, KATHLEEN A (DO)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:A
Last Name:LEINEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 S 1ST ST STE 100
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:IL
Mailing Address - Zip Code:61739-1509
Mailing Address - Country:US
Mailing Address - Phone:815-592-2380
Mailing Address - Fax:
Practice Address - Street 1:106 S 1ST ST STE 100
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:IL
Practice Address - Zip Code:61739-1509
Practice Address - Country:US
Practice Address - Phone:815-592-2380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-29
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0919207Q00000X
IL036121354207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXN0919OtherTX LICENSE
IL036121354Medicaid
TX209713102Medicaid