Provider Demographics
NPI:1790845022
Name:LOWE, LAKISKA (OTRL)
Entity Type:Individual
Prefix:
First Name:LAKISKA
Middle Name:
Last Name:LOWE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 71721
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31708-1721
Mailing Address - Country:US
Mailing Address - Phone:229-395-2845
Mailing Address - Fax:229-883-4025
Practice Address - Street 1:527 DIVINE DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-8993
Practice Address - Country:US
Practice Address - Phone:229-395-2845
Practice Address - Fax:229-883-4025
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003481171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor