Provider Demographics
NPI:1386614618
Name:LUKE, LESLIE DALE (RNC FNP WHNP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:DALE
Last Name:LUKE
Suffix:
Gender:F
Credentials:RNC FNP WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 W. EDWARDS
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468
Mailing Address - Country:US
Mailing Address - Phone:660-562-2273
Mailing Address - Fax:660-562-3530
Practice Address - Street 1:106 W. EDWARDS
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468
Practice Address - Country:US
Practice Address - Phone:660-562-2273
Practice Address - Fax:660-562-3530
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO122210363LF0000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO424794410Medicaid
MOM49B872Medicare ID - Type Unspecified
MO424794410Medicaid