Healthcare Provider Details

I. General information

NPI: 1669048211
Provider Name (Legal Business Name): CEREASA LEEANN PATTERSON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CEREASA LEEANN MOORE

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7701 E KELLOGG DR STE 490
WICHITA KS
67207-1716
US

IV. Provider business mailing address

245 N WACO ST STE 220
WICHITA KS
67202-1102
US

V. Phone/Fax

Practice location:
  • Phone: 316-722-2138
  • Fax:
Mailing address:
  • Phone: 316-722-2138
  • Fax: 833-464-2530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-80521-032
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number13-134071-032
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: