Provider Demographics
NPI:1619747268
Name:SAMPSON, LAKIAH R
Entity type:Individual
Prefix:
First Name:LAKIAH
Middle Name:R
Last Name:SAMPSON
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 1:8613 DENISON AVE UNIT 3
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-4923
Mailing Address - Country:US
Mailing Address - Phone:216-250-6202
Mailing Address - Fax:
Practice Address - Street 1:8613 DENISON AVE UNIT 3
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-4923
Practice Address - Country:US
Practice Address - Phone:216-250-6202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1832101172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0483962Medicaid