Provider Demographics
NPI:1376142620
Name:MOORE, LAKISHA DAVONDA
Entity Type:Individual
Prefix:
First Name:LAKISHA
Middle Name:DAVONDA
Last Name:MOORE
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 1:4060 VICTORIA BLVD APT 107
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-4284
Mailing Address - Country:US
Mailing Address - Phone:757-968-0398
Mailing Address - Fax:757-251-3801
Practice Address - Street 1:5 W QUEENS WAY STE 203
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-4084
Practice Address - Country:US
Practice Address - Phone:757-964-6297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide