Healthcare Provider Details

I. General information

NPI: 1467277848
Provider Name (Legal Business Name): LAKOSHA S DWELLINGHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 11/20/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5656 KELLEY ST
HOUSTON TX
77026-1967
US

IV. Provider business mailing address

3701 LUELLA BLVD APT 1906
LA PORTE TX
77571-3698
US

V. Phone/Fax

Practice location:
  • Phone: 713-566-6000
  • Fax:
Mailing address:
  • Phone: 832-665-5189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1044948
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: