Healthcare Provider Details

I. General information

NPI: 1174060016
Provider Name (Legal Business Name): MS. LAKEISHA HOLMES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WENGATE RD
OWINGS MILLS MD
21117-3322
US

IV. Provider business mailing address

100 WENGATE RD
OWINGS MILLS MD
21117-3322
US

V. Phone/Fax

Practice location:
  • Phone: 410-205-5194
  • Fax:
Mailing address:
  • Phone: 410-205-5194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
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: