Provider Demographics
NPI:1154903680
Name:SHIVERS, LAKISHA M (NP)
Entity type:Individual
Prefix:
First Name:LAKISHA
Middle Name:M
Last Name:SHIVERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LAKISHA
Other - Middle Name:MONIKE
Other - Last Name:STEVENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2626 HALPERIN AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2631
Mailing Address - Country:US
Mailing Address - Phone:718-618-0401
Mailing Address - Fax:347-479-1303
Practice Address - Street 1:2015 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4303
Practice Address - Country:US
Practice Address - Phone:718-583-7736
Practice Address - Fax:718-537-6180
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30055363LP0808X
MS904795363LP0808X
NYF405244363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty