Provider Demographics
NPI:1467025361
Name:MOORE, LAKEYSHA DEMAR
Entity Type:Individual
Prefix:
First Name:LAKEYSHA
Middle Name:DEMAR
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 1:5109 ROCK BEAUTY CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4789
Mailing Address - Country:US
Mailing Address - Phone:240-346-8178
Mailing Address - Fax:240-607-7057
Practice Address - Street 1:5109 ROCK BEAUTY CT
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4789
Practice Address - Country:US
Practice Address - Phone:240-346-8178
Practice Address - Fax:240-607-7057
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDNAOtherHAIR LOSS PRACTITIONER