Provider Demographics
NPI:1760633986
Name:MOBLEY, LAKISHA Y (APRN)
Entity Type:Individual
Prefix:
First Name:LAKISHA
Middle Name:Y
Last Name:MOBLEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 CRESCENT ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3453
Mailing Address - Country:US
Mailing Address - Phone:781-214-1018
Mailing Address - Fax:
Practice Address - Street 1:1019 CRESCENT ST STE 2
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3453
Practice Address - Country:US
Practice Address - Phone:781-214-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN268182363LW0102X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004038709Medicaid
CTD400002169 - C00023Medicare PIN
CTD400002170 - C00814Medicare PIN