Provider Demographics
NPI:1790252740
Name:HARRIS, RAKESHA ELEASE
Entity Type:Individual
Prefix:
First Name:RAKESHA
Middle Name:ELEASE
Last Name:HARRIS
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 1:4764 SE GROUPER AVE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-8839
Mailing Address - Country:US
Mailing Address - Phone:772-353-9450
Mailing Address - Fax:
Practice Address - Street 1:4764 SE GROUPER AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-8839
Practice Address - Country:US
Practice Address - Phone:772-353-9450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL729412Medicaid