Provider Demographics
NPI:1528720612
Name:ETHERIDGE, LEEANDRA LD
Entity type:Individual
Prefix:
First Name:LEEANDRA
Middle Name:LD
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3260 N HAYDEN RD STE 210-14
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-6649
Mailing Address - Country:US
Mailing Address - Phone:480-659-3453
Mailing Address - Fax:480-809-4646
Practice Address - Street 1:3260 N HAYDEN RD # 210-14
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6649
Practice Address - Country:US
Practice Address - Phone:602-435-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5Medicaid
AZ871421001OtherIN HOME HEALTH CARE
AZ87-1421001Medicaid
AZ152870612OtherNPI