Provider Demographics
NPI:1699331934
Name:JOHNSON, LAKEATA (LICENSED COSMETOLOGI)
Entity type:Individual
Prefix:
First Name:LAKEATA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LICENSED COSMETOLOGI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2070 AYRSLEY TOWN BLVD UNIT A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-4056
Mailing Address - Country:US
Mailing Address - Phone:980-228-6653
Mailing Address - Fax:
Practice Address - Street 1:2070 AYRSLEY TOWN BLVD UNIT A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4056
Practice Address - Country:US
Practice Address - Phone:980-228-6653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC77340335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier