Provider Demographics
NPI:1578118378
Name:PARKS, LAKISHA SHANTAYE (LPN)
Entity type:Individual
Prefix:
First Name:LAKISHA
Middle Name:SHANTAYE
Last Name:PARKS
Suffix:
Gender:
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 S 25TH ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48601-6337
Mailing Address - Country:US
Mailing Address - Phone:989-372-3691
Mailing Address - Fax:
Practice Address - Street 1:4200 EMERALD DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:MI
Practice Address - Zip Code:48722-9520
Practice Address - Country:US
Practice Address - Phone:989-372-3691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2025-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703117282164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse