Provider Demographics
NPI:1639439557
Name:LUCAS, MALISA SHA'REE (COSMETOLOGIST)
Entity Type:Individual
Prefix:
First Name:MALISA
Middle Name:SHA'REE
Last Name:LUCAS
Suffix:
Gender:F
Credentials:COSMETOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6123 GREENS HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-2109
Mailing Address - Country:US
Mailing Address - Phone:919-638-7227
Mailing Address - Fax:
Practice Address - Street 1:5410 NC HIGHWAY 55
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-7800
Practice Address - Country:US
Practice Address - Phone:919-638-7227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC84271174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist