Provider Demographics
NPI:1932742822
Name:PERRY, LAKEISHA (AVN)
Entity Type:Individual
Prefix:
First Name:LAKEISHA
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:AVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5843 EAGLE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-1148
Mailing Address - Country:US
Mailing Address - Phone:314-308-5219
Mailing Address - Fax:
Practice Address - Street 1:1851 ARROWPOINT DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63138-1515
Practice Address - Country:US
Practice Address - Phone:314-308-5219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019028291364S00000X, 364S00000X, 364SH0200X, 364S00000X
MOP137000003172A00000X
172V00000X, 251E00000X, 3336M0003X
MO174400000X
MO20190228291364SE0003X, 364SH0200X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No172A00000XOther Service ProvidersDriver
No172V00000XOther Service ProvidersCommunity Health Worker
No174400000XOther Service ProvidersSpecialist
No251E00000XAgenciesHome Health
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
No364SE0003XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistEmergencyGroup - Multi-Specialty
No364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome HealthGroup - Multi-Specialty
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420077265Medicaid
MO830077066Medicaid