Provider Demographics
NPI:1093200313
Name:TERRELL, LAKIESHA
Entity type:Individual
Prefix:
First Name:LAKIESHA
Middle Name:
Last Name:TERRELL
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:PO BOX 572
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48046-0572
Mailing Address - Country:US
Mailing Address - Phone:586-553-4550
Mailing Address - Fax:734-391-8272
Practice Address - Street 1:10101 ROLAN MEADOWS DR
Practice Address - Street 2:
Practice Address - City:VAN BUREN TWP
Practice Address - State:MI
Practice Address - Zip Code:48111-8104
Practice Address - Country:US
Practice Address - Phone:586-553-4550
Practice Address - Fax:734-391-8272
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI372500000X
372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider