Provider Demographics
NPI:1629896030
Name:PENSON, LAKEIIA RAE'CHELLE
Entity type:Individual
Prefix:
First Name:LAKEIIA
Middle Name:RAE'CHELLE
Last Name:PENSON
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 1:17508 SCUDDER CT
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-1651
Mailing Address - Country:US
Mailing Address - Phone:323-707-3661
Mailing Address - Fax:
Practice Address - Street 1:17508 SCUDDER CT
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-1651
Practice Address - Country:US
Practice Address - Phone:323-707-3661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032332363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health