Provider Demographics
NPI:1235753427
Name:LEE, TAKITA LYSHAWN
Entity Type:Individual
Prefix:
First Name:TAKITA
Middle Name:LYSHAWN
Last Name:LEE
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 1:682 NE SAINT CLAIR ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-1719
Mailing Address - Country:US
Mailing Address - Phone:386-623-5738
Mailing Address - Fax:
Practice Address - Street 1:682 NE SAINT CLAIR ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-1719
Practice Address - Country:US
Practice Address - Phone:386-623-5738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver