Provider Demographics
NPI:1417377094
Name:ETHERIDGE, LESLIE (FNP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:ETHERIDGE
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 1:2700 CLAY EDWARDS DR STE 240
Mailing Address - Street 2:
Mailing Address - City:NORTH KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-3254
Mailing Address - Country:US
Mailing Address - Phone:816-691-5287
Mailing Address - Fax:816-346-7690
Practice Address - Street 1:2700 CLAY EDWARDS DR STE 240
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3254
Practice Address - Country:US
Practice Address - Phone:816-691-5287
Practice Address - Fax:816-346-7690
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS77104363L00000X
MO2013033429363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner