Provider Demographics
NPI:1114797313
Name:GRADY, LAKISHA
Entity Type:Individual
Prefix:
First Name:LAKISHA
Middle Name:
Last Name:GRADY
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 1:2213 DREXEL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46806-1382
Mailing Address - Country:US
Mailing Address - Phone:260-715-5312
Mailing Address - Fax:
Practice Address - Street 1:2213 DREXEL AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-1382
Practice Address - Country:US
Practice Address - Phone:260-715-5312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist