Provider Demographics
NPI:1477241487
Name:JOHNSON, LAKEISHA LEE
Entity Type:Individual
Prefix:
First Name:LAKEISHA
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAKEISHA
Other - Middle Name:LEE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3400 COTTAGE WAY STE G2
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1474
Mailing Address - Country:US
Mailing Address - Phone:209-793-2013
Mailing Address - Fax:
Practice Address - Street 1:3400 COTTAGE WAY STE G2
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-1474
Practice Address - Country:US
Practice Address - Phone:209-793-2013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA751757283374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA92-2335779Medicaid