Provider Demographics
NPI:1538824974
Name:VAN ZANDT MUCKELROY, LAKEITHA LASHUN (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:LAKEITHA
Middle Name:LASHUN
Last Name:VAN ZANDT MUCKELROY
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 E DEBBIE LN STE 210
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3305
Mailing Address - Country:US
Mailing Address - Phone:817-891-1169
Mailing Address - Fax:
Practice Address - Street 1:1301 E DEBBIE LN STE 210
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3305
Practice Address - Country:US
Practice Address - Phone:817-891-1169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX845060163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse