Provider Demographics
NPI:1326932278
Name:BERRY, LAKISHA MONIQUE
Entity type:Individual
Prefix:
First Name:LAKISHA
Middle Name:MONIQUE
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9226 PINEVILLE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-6175
Mailing Address - Country:US
Mailing Address - Phone:248-943-8510
Mailing Address - Fax:
Practice Address - Street 1:706 LOYOLA DR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5222
Practice Address - Country:US
Practice Address - Phone:248-943-8510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-05
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLB62732254300172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver