Provider Demographics
NPI:1376276667
Name:HEADLEY, LAKISHA R (CBD,CPD)
Entity Type:Individual
Prefix:
First Name:LAKISHA
Middle Name:R
Last Name:HEADLEY
Suffix:
Gender:F
Credentials:CBD,CPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 MILTON AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-1508
Mailing Address - Country:US
Mailing Address - Phone:470-243-0906
Mailing Address - Fax:
Practice Address - Street 1:44 MILTON AVE STE 260
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-1508
Practice Address - Country:US
Practice Address - Phone:470-243-0906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty