Healthcare Provider Details

I. General information

NPI: 1770187676
Provider Name (Legal Business Name): LAKESHIA DYANNE HARDEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 11/23/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 CRESTWAY DR SUITE 200 B
SAN ANTONIO TX
78219
US

IV. Provider business mailing address

4414 STRADFORD PL
SAN ANTONIO TX
78217-1368
US

V. Phone/Fax

Practice location:
  • Phone: 210-310-3864
  • Fax:
Mailing address:
  • Phone: 210-994-4551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number346215
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: