Provider Demographics
NPI:1457859118
Name:CALDWELL, LACRESHA NICOLE
Entity Type:Individual
Prefix:
First Name:LACRESHA
Middle Name:NICOLE
Last Name:CALDWELL
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 1:1213 KELLOGG DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4944
Mailing Address - Country:US
Mailing Address - Phone:321-202-0335
Mailing Address - Fax:352-609-5115
Practice Address - Street 1:1213 KELLOGG DR
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4944
Practice Address - Country:US
Practice Address - Phone:321-202-0335
Practice Address - Fax:352-609-5115
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$OtherSS