Provider Demographics
NPI:1659847507
Name:ELLIS, LAKESHA DIANNA
Entity Type:Individual
Prefix:
First Name:LAKESHA
Middle Name:DIANNA
Last Name:ELLIS
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 1:708 BLANKS AND HOGAN RD
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:MS
Mailing Address - Zip Code:39367-3054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:708 BLANKS AND HOGAN RD
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:MS
Practice Address - Zip Code:39367-3054
Practice Address - Country:US
Practice Address - Phone:601-410-1736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)