Provider Demographics
NPI:1689232407
Name:BANNISTER, LAKESHA
Entity Type:Individual
Prefix:
First Name:LAKESHA
Middle Name:
Last Name:BANNISTER
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 1:5802 N 80TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-1717
Mailing Address - Country:US
Mailing Address - Phone:414-722-3258
Mailing Address - Fax:
Practice Address - Street 1:5802 N 80TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-1717
Practice Address - Country:US
Practice Address - Phone:414-722-3258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0017488310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility