Healthcare Provider Details

I. General information

NPI: 1366074569
Provider Name (Legal Business Name): LEKESHIA SMITH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY RD STE 374B
SAINT LOUIS MO
63128-2178
US

IV. Provider business mailing address

10004 KENNERLY RD STE 374B
SAINT LOUIS MO
63128-2178
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-9669
  • Fax: 314-842-1017
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018001601
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: