MEDICARE: LAKEISHA MOORE

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	164W00000X	Licensed Practical Nurse	4703126437	MI

General Provider Information

NPI Number	:	1245001957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKEISHA MOORE

Provider Business Mailing Address
First Line	:	31 ASH DR
Second Line	:
City	:	VAN BUREN TOWNSHIP
State	:	MI
Zip	:	48111-2592
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	31 ASH DR
Second Line	:
City	:	VAN BUREN TOWNSHIP
State	:	MI
Zip	:	48111-2592
Country	:	US
Telephone Number	:	734-444-4880
Fax Number	:

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

Provider Enumeration Date	:	01/11/2024
Last Update Date	:	01/11/2024

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Directions to “ LAKEISHA MOORE ” Practice Location

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