1447774823 NPI number — LAKIESHA JOHNSON SQUIREWELL PMHNP

Table of content: LAKIESHA JOHNSON SQUIREWELL PMHNP (NPI 1447774823)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447774823 NPI number — LAKIESHA JOHNSON SQUIREWELL PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SQUIREWELL
Provider First Name:
LAKIESHA
Provider Middle Name:
JOHNSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447774823
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10130 PERIMETER PARKWAY STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-849-7379
Provider Business Mailing Address Fax Number:
855-857-7333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10130 PERIMETER PKWY STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28216-0197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-948-3536
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  5009714 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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