Healthcare Provider Details

I. General information

NPI: 1649986639
Provider Name (Legal Business Name): LAKRESHA MIREAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 4TH ST N
FARGO ND
58102-4818
US

IV. Provider business mailing address

115 UNIVERSITY DR N STE 102
FARGO ND
58102-4667
US

V. Phone/Fax

Practice location:
  • Phone: 701-595-9909
  • Fax:
Mailing address:
  • Phone: 701-595-9909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: