Provider Demographics
NPI:1558007526
Name:MATTOX, LAKENDRA MYNETTA
Entity Type:Individual
Prefix:
First Name:LAKENDRA
Middle Name:MYNETTA
Last Name:MATTOX
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 1:3172 N 75TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2765
Mailing Address - Country:US
Mailing Address - Phone:414-322-8257
Mailing Address - Fax:
Practice Address - Street 1:3172 N 75TH ST APT 1
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2765
Practice Address - Country:US
Practice Address - Phone:414-322-8257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI376K00000X
376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide