Provider Demographics
NPI:1720523129
Name:MOORE, LAKESHIA (LPN)
Entity Type:Individual
Prefix:
First Name:LAKESHIA
Middle Name:
Last Name:MOORE
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 1:1334 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-4716
Mailing Address - Country:US
Mailing Address - Phone:419-870-2090
Mailing Address - Fax:
Practice Address - Street 1:311 E MARKET ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4535
Practice Address - Country:US
Practice Address - Phone:419-222-4474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-21
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.161003-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0254786Medicaid