Provider Demographics
NPI:1881073252
Name:COOPER, LAKESHIA
Entity type:Individual
Prefix:
First Name:LAKESHIA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAKESHIA
Other - Middle Name:JEANNETTE
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PCA
Mailing Address - Street 1:550 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2148
Mailing Address - Country:US
Mailing Address - Phone:631-842-1639
Mailing Address - Fax:631-842-0165
Practice Address - Street 1:550 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2148
Practice Address - Country:US
Practice Address - Phone:631-842-1639
Practice Address - Fax:631-842-0165
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00287717172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker