Provider Demographics
NPI:1578241519
Name:PETEN, LAKISHA
Entity Type:Individual
Prefix:
First Name:LAKISHA
Middle Name:
Last Name:PETEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LAKISHA
Other - Middle Name:
Other - Last Name:PETEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:107 WALTER PAYTON DR # 220
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-3738
Mailing Address - Country:US
Mailing Address - Phone:601-588-6689
Mailing Address - Fax:
Practice Address - Street 1:950 HWY 13 S
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429
Practice Address - Country:US
Practice Address - Phone:601-588-6689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier