Provider Demographics
NPI:1477961100
Name:DRAKE, LETISSHA M
Entity Type:Individual
Prefix:MISS
First Name:LETISSHA
Middle Name:M
Last Name:DRAKE
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 1:1969 OLD CHARLOTTE HWY STE E
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-9151
Mailing Address - Country:US
Mailing Address - Phone:704-225-3451
Mailing Address - Fax:704-225-9796
Practice Address - Street 1:1969 OLD CHARLOTTE HWY STE E
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-9151
Practice Address - Country:US
Practice Address - Phone:704-225-3451
Practice Address - Fax:704-225-9796
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC29396174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist