Provider Demographics
NPI:1972353563
Name:WILSON, LAKEISHA
Entity type:Individual
Prefix:
First Name:LAKEISHA
Middle Name:
Last Name:WILSON
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 1:2131 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45403-2001
Mailing Address - Country:US
Mailing Address - Phone:513-295-9626
Mailing Address - Fax:
Practice Address - Street 1:2131 E 4TH ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45403-2001
Practice Address - Country:US
Practice Address - Phone:937-825-5012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X, 376J00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No251E00000XAgenciesHome Health
No376J00000XNursing Service Related ProvidersHomemaker