Provider Demographics
NPI:1952739658
Name:LAKES, KENYA LOUISE
Entity type:Individual
Prefix:
First Name:KENYA
Middle Name:LOUISE
Last Name:LAKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KENYA
Other - Middle Name:LOUISE
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-3109
Mailing Address - Country:US
Mailing Address - Phone:855-492-8878
Mailing Address - Fax:
Practice Address - Street 1:1029 E 5TH ST
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-3301
Practice Address - Country:US
Practice Address - Phone:765-825-0543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004517A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN06004517AOtherINDIANA PROFESSIONAL LICENSING AGENCY