Healthcare Provider Details

I. General information

NPI: 1699126516
Provider Name (Legal Business Name): LAKEISHA FAIR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 OXFORD RD
MANSFIELD LA
71052
US

IV. Provider business mailing address

722 OXFORD RD
MANSFIELD LA
71052-5015
US

V. Phone/Fax

Practice location:
  • Phone: 318-507-8077
  • Fax: 318-213-0905
Mailing address:
  • Phone: 318-507-8077
  • Fax: 318-213-0905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: