Provider Demographics
NPI:1447883541
Name:MOORE, LAKIESHA LASHA
Entity type:Individual
Prefix:
First Name:LAKIESHA
Middle Name:LASHA
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 MAGNOLIA LAKES DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-5196
Mailing Address - Country:US
Mailing Address - Phone:901-503-4036
Mailing Address - Fax:
Practice Address - Street 1:971 OAKMONT PL APT 2
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38107-3210
Practice Address - Country:US
Practice Address - Phone:901-503-4036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care