Provider Demographics
NPI:1639393275
Name:LEIBLE, LORELEI (NP)
Entity Type:Individual
Prefix:
First Name:LORELEI
Middle Name:
Last Name:LEIBLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:3250 GORDONVILLE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5056
Practice Address - Country:US
Practice Address - Phone:573-334-9641
Practice Address - Fax:573-331-4130
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2002014828363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1639393275Medicaid
MO1639393275OtherTRIWEST
MO926539OtherHEALTHLINK