Provider Demographics
NPI:1093570194
Name:ROSS, LAKESHA
Entity Type:Individual
Prefix:
First Name:LAKESHA
Middle Name:
Last Name:ROSS
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 1:108 HICKORY BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-8494
Mailing Address - Country:US
Mailing Address - Phone:336-646-8471
Mailing Address - Fax:
Practice Address - Street 1:108 HICKORY BLUFF CT
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-8494
Practice Address - Country:US
Practice Address - Phone:336-646-8471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000026421807172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver