Provider Demographics
NPI:1093443228
Name:LAKE, MICHELLE DUPRE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DUPRE
Last Name:LAKE
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 1:1070 S LAKE DR STE B
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29073-3701
Mailing Address - Country:US
Mailing Address - Phone:803-785-6550
Mailing Address - Fax:803-785-6556
Practice Address - Street 1:1070 S LAKE DR STE B
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29073-3701
Practice Address - Country:US
Practice Address - Phone:803-785-6550
Practice Address - Fax:803-785-6556
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0062323163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health