Provider Demographics
NPI:1871157198
Name:WEATHERSPOON, LAKEYSHA NICHELLE
Entity type:Individual
Prefix:
First Name:LAKEYSHA
Middle Name:NICHELLE
Last Name:WEATHERSPOON
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 1:117 OVERTON DR
Mailing Address - Street 2:
Mailing Address - City:PLANTERSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38862
Mailing Address - Country:US
Mailing Address - Phone:662-205-4115
Mailing Address - Fax:
Practice Address - Street 1:3558 KIRBY PKWY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-4243
Practice Address - Country:US
Practice Address - Phone:901-566-1203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25798363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner