Healthcare Provider Details

I. General information

NPI: 1932753803
Provider Name (Legal Business Name): LAKISHA DUFFIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 MERIDIAN ST NW
NORMAL AL
35762-7500
US

IV. Provider business mailing address

3784 UNIVERSITY DR NW APT 122
HUNTSVILLE AL
35816-3156
US

V. Phone/Fax

Practice location:
  • Phone: 256-372-4011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: