=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841045341
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAKISHA MCDONALD NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2024
-----------------------------------------------------
Last Update Date | 12/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1583 HEALTH CARE DR
-----------------------------------------------------
City | ROCK HILL
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29732-3858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-329-7772
-----------------------------------------------------
Fax | 803-329-9821
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3004 PARKER GREEN TRL
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28269-1490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-615-7829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WN0800X
-----------------------------------------------------
Taxonomy Name | Neuroscience Registered Nurse
-----------------------------------------------------
License Number | 190429
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 28951
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------