Healthcare Provider Details

I. General information

NPI: 1417377094
Provider Name (Legal Business Name): LESLIE ETHERIDGE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 GILLHAM RD
KANSAS CITY MO
64108-4619
US

IV. Provider business mailing address

2700 CLAY EDWARDS DR STE 240
NORTH KANSAS CITY MO
64116-3254
US

V. Phone/Fax

Practice location:
  • Phone: 816-234-3000
  • Fax: 816-302-9939
Mailing address:
  • Phone: 816-691-5287
  • Fax: 816-346-7690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2013033429
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number77104
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: