Provider Demographics
NPI:1790318848
Name:BRISBANE, LAKESHA NICOLE
Entity Type:Individual
Prefix:
First Name:LAKESHA
Middle Name:NICOLE
Last Name:BRISBANE
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 1:960 WOODY HILLS DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-4124
Mailing Address - Country:US
Mailing Address - Phone:931-378-2405
Mailing Address - Fax:
Practice Address - Street 1:950 HIGHPOINT DR
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-2570
Practice Address - Country:US
Practice Address - Phone:731-394-1145
Practice Address - Fax:855-632-8329
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3014418363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
14619675OtherCAQH