Provider Demographics
NPI:1932819216
Name:RUSSELL, LAKISHA (LMT)
Entity Type:Individual
Prefix:MS
First Name:LAKISHA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10273 JOLYNN RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-6649
Mailing Address - Country:US
Mailing Address - Phone:904-586-6940
Mailing Address - Fax:
Practice Address - Street 1:10273 JOLYNN RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-6649
Practice Address - Country:US
Practice Address - Phone:904-586-6940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA100675225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist