Provider Demographics
NPI:1700342060
Name:POPE, LAKETRIA (LPN)
Entity Type:Individual
Prefix:
First Name:LAKETRIA
Middle Name:
Last Name:POPE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WILSHIRE BLVD STE 221
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-5369
Mailing Address - Country:US
Mailing Address - Phone:407-900-0519
Mailing Address - Fax:
Practice Address - Street 1:300 WILSHIRE BLVD STE 221
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-5369
Practice Address - Country:US
Practice Address - Phone:407-900-0519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-12
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5235545164W00000X
261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101367700Medicaid