Provider Demographics
NPI:1649986639
Name:MIREAU, LAKRESHA
Entity type:Individual
Prefix:
First Name:LAKRESHA
Middle Name:
Last Name:MIREAU
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 1:115 UNIVERSITY DR N STE 102
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4667
Mailing Address - Country:US
Mailing Address - Phone:701-595-9909
Mailing Address - Fax:
Practice Address - Street 1:222 4TH ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4818
Practice Address - Country:US
Practice Address - Phone:701-595-9909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ND172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver