Provider Demographics
NPI:1124762943
Name:GRESHAM, LACHUNTE'
Entity type:Individual
Prefix:MRS
First Name:LACHUNTE'
Middle Name:
Last Name:GRESHAM
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 1:610 WOODFIN RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23605-1138
Mailing Address - Country:US
Mailing Address - Phone:757-236-0864
Mailing Address - Fax:
Practice Address - Street 1:610 WOODFIN RD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23605-1138
Practice Address - Country:US
Practice Address - Phone:757-236-0864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA118497930OtherDUN NUMBER