Healthcare Provider Details

I. General information

NPI: 1043146194
Provider Name (Legal Business Name): LAKETA BUMPERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6118 SAINT GILES ST STE 130
RALEIGH NC
27612-7099
US

IV. Provider business mailing address

6118 SAINT GILES ST STE 130
RALEIGH NC
27612-7099
US

V. Phone/Fax

Practice location:
  • Phone: 919-910-0800
  • Fax:
Mailing address:
  • Phone: 919-910-0800
  • Fax: 919-341-5068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number88922
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: