NPIMap

Individual provider Active NPI

Dietra Leigh Angelly, FNP-C

  • Nurse Practitioner
  • Marion, IL
National Provider Identifier
1902371313
Registry record updated Apr 8, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nurse PractitionerTaxonomy code 363L00000X
License
209018044 Issued in IL
Practice address
3411 Professional Park Dr
Marion, IL 62959-6394
Phone
(618) 969-8630
Fax
(618) 993-1421
NPI assigned
Oct 11, 2018
Last updated
Apr 8, 2024By the provider in NPPES
Sex
Female
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Apr 8, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Nurse Practitioner 363L00000X 209018044 IL Primary
Family Nurse Practitioner 363LF0000X 209018044 IL

Addresses

Primary practice location

3411 Professional Park Dr
Marion, IL 62959-6394

Mailing address

408 Lincoln Dr Ste B
Herrin, IL 62948-3790
Phone (618) 351-4980

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20190130001729 IL Practitioner - Nurse Practitioner 9931356276 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2018
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Deaconess Illinois Clinic IncGroup PAC ID 5092187021, 19 clinicians

Practice addresses (Care Compare)

205 Bailey LN
Benton, IL 62812-1921
Phone (618) 882-4200

303 S Commercial St
Harrisburg, IL 62946-2125
Phone (618) 918-6060

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
83.16 of 100Reported as group
Quality
70.69
Promoting interoperability
99
Improvement activities
40
Cost
71.02

Merit-based Incentive Payment System (MIPS)

Final score
77.51 of 100Reported as group
Quality
49.04
Promoting interoperability
95
Improvement activities
40
Cost
69.42

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Deaconess Illinois Specialty Clinic, Inc. Nurse Practitioner CurrentSince Jan 14, 2023 Accepting new patients
Deaconess Illinois Specialty Clinic, Inc. Nurse Practitioner CurrentSince Jan 14, 2023 Accepting new patients
Deaconess Illinois Clinic, Inc Nurse Practitioner CurrentSince Jan 14, 2023 Accepting new patients
Deaconess Illinois Clinic, Inc CurrentSince Jan 14, 2023 Accepting new patients
Deaconess Illinois Clinic, Inc Nurse Practitioner Current Accepting new patients
Deaconess Illinois Specialty Clinic, Inc. Nurse Practitioner Current Accepting new patients
Deaconess Illinois Clinic, Inc Nurse Practitioner Past Accepting new patients
Deaconess Illinois Clinic, Inc Past Accepting new patients
Deaconess Illinois Clinic, Inc Nurse Practitioner Past Accepting new patients
Marion Surgery Center LTD PastSince Apr 20, 2008 Accepting new patients

Locations

205 Bailey Ln
Benton, IL 62812
Phone (618) 435-8189

1000 Eleven S
Columbia, IL 62236
Phone (618) 281-7010

303 S Commercial St
Harrisburg, IL 62946
Phone (618) 767-6050

2700 W Deyoung St
Marion, IL 62959
Phone (618) 969-8633

2700 W Deyoung St
Ste F
Marion, IL 62959
Phone (618) 457-5330

3411 Professional Park Dr
Marion, IL 62959
Phone (618) 969-8630

509 Hamacher St
Waterloo, IL 62298
Phone (618) 939-3939

Interoperability endpoints

  • Direct secure messaging: dangelly288686@direct.deaconess.com
  • Direct secure messaging: dietra.angelly.1@27782.direct.athenahealth.com

Organizations & group practices 10

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 9

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1539216000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1712534400000",
    "number": "1902371313",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "408 LINCOLN DR STE B",
            "city": "HERRIN",
            "state": "IL",
            "postal_code": "629483790",
            "telephone_number": "618-351-4980",
            "fax_number": "618-993-8418"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3411 PROFESSIONAL PARK DR",
            "city": "MARION",
            "state": "IL",
            "postal_code": "629596394",
            "telephone_number": "618-969-8630",
            "fax_number": "618-993-1421"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ANGELLY",
        "first_name": "DIETRA",
        "middle_name": "LEIGH",
        "credential": "FNP-C",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2018-10-11",
        "last_updated": "2024-04-08",
        "certification_date": "2024-04-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "IL",
            "license": "209018044",
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "IL",
            "license": "209018044",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Marion, IL

Sources for this page

Verify at the official NPI Registry.