Provider Demographics
NPI:1114684016
Name:LAKE, MERRILL J
Entity Type:Individual
Prefix:
First Name:MERRILL
Middle Name:J
Last Name:LAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 WILLOW STREET
Mailing Address - Street 2:
Mailing Address - City:CHEVAK
Mailing Address - State:AK
Mailing Address - Zip Code:99563
Mailing Address - Country:US
Mailing Address - Phone:907-858-7069
Mailing Address - Fax:907-858-7456
Practice Address - Street 1:212 WILLOW STREET
Practice Address - Street 2:
Practice Address - City:CHEVAK
Practice Address - State:AK
Practice Address - Zip Code:99563
Practice Address - Country:US
Practice Address - Phone:907-858-7069
Practice Address - Fax:907-858-7456
Is Sole Proprietor?:No
Enumeration Date:2021-11-26
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker