Provider Demographics
NPI:1134683030
Name:BAKER, LAKEITHA CHANTEL
Entity Type:Individual
Prefix:
First Name:LAKEITHA
Middle Name:CHANTEL
Last Name:BAKER
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:PO BOX 323
Mailing Address - Street 2:
Mailing Address - City:GEISMAR
Mailing Address - State:LA
Mailing Address - Zip Code:70734-0323
Mailing Address - Country:US
Mailing Address - Phone:225-313-0658
Mailing Address - Fax:
Practice Address - Street 1:35761 SAM BAKER DR
Practice Address - Street 2:
Practice Address - City:GEISMAR
Practice Address - State:LA
Practice Address - Zip Code:70734-3348
Practice Address - Country:US
Practice Address - Phone:225-313-0658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0000000000405300000X
172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No405300000XOther Service ProvidersPrevention Professional