Provider Demographics
NPI:1568157287
Name:HENRY, LAKEISHA
Entity Type:Individual
Prefix:
First Name:LAKEISHA
Middle Name:
Last Name:HENRY
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 1:2168 CASTLE PINES DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-5440
Mailing Address - Country:US
Mailing Address - Phone:919-637-9261
Mailing Address - Fax:
Practice Address - Street 1:2168 CASTLE PINES DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-5440
Practice Address - Country:US
Practice Address - Phone:919-637-9261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-07
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39706700172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver