Healthcare Provider Details

I. General information

NPI: 1033422639
Provider Name (Legal Business Name): LAKESHIA KIJUAN EALY NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2010
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7602 GREAT TRINITY FOREST WAY
DALLAS TX
75217-6650
US

IV. Provider business mailing address

7602 GREAT TRINITY FOREST WAY
DALLAS TX
75217-6650
US

V. Phone/Fax

Practice location:
  • Phone: 469-779-2000
  • Fax: 877-441-1590
Mailing address:
  • Phone: 469-779-2000
  • Fax: 877-441-1590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number690537
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP137442
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: