Provider Demographics
NPI:1255196945
Name:LAKTIB, RADOUANE (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:RADOUANE
Middle Name:
Last Name:LAKTIB
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10411 GOLDENBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3169
Mailing Address - Country:US
Mailing Address - Phone:813-857-1181
Mailing Address - Fax:
Practice Address - Street 1:4202 E FOWLER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-8000
Practice Address - Country:US
Practice Address - Phone:813-974-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11031382363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121788700Medicaid
FLERQTYOtherBLUE CROSS BLUE SHIELD