Provider Demographics
NPI:1902544976
Name:LONG, LAKEISHA MACK (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LAKEISHA
Middle Name:MACK
Last Name:LONG
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41247 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:SORRENTO
Mailing Address - State:LA
Mailing Address - Zip Code:70778-3426
Mailing Address - Country:US
Mailing Address - Phone:504-319-6078
Mailing Address - Fax:
Practice Address - Street 1:4055 VALLEY VIEW LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-5074
Practice Address - Country:US
Practice Address - Phone:504-319-6078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA223994363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily