Healthcare Provider Details

I. General information

NPI: 1013821578
Provider Name (Legal Business Name): CLARISSA LEIDHOLT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 S 143RD ST E
WICHITA KS
67230-9547
US

IV. Provider business mailing address

2055 S 143RD ST E
WICHITA KS
67230-9547
US

V. Phone/Fax

Practice location:
  • Phone: 316-973-9990
  • Fax: 316-973-9995
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number13-134043
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: