MEDICARE: LAKIA SHANNON KING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	222Q00000X	Developmental Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225689557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKIA SHANNON KING

Provider Business Mailing Address
First Line	:	635 SHORT HILLS LN UNIT 103
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32905-2272
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	635 SHORTHILLS LANE
Second Line	:	UNIT103
City	:	MELBOURNE
State	:	FL
Zip	:	32905-3290
Country	:	US
Telephone Number	:	860-573-5303
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2019
Last Update Date	:	06/30/2022

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Directions to “ LAKIA SHANNON KING ” Practice Location

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