Provider Demographics
NPI:1275050288
Name:LAKE, MOSUNMOLA SANDRA (DNP, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MOSUNMOLA
Middle Name:SANDRA
Last Name:LAKE
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10801 GREEN ASH LN
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-3851
Mailing Address - Country:US
Mailing Address - Phone:301-263-4890
Mailing Address - Fax:
Practice Address - Street 1:6215 GREENBELT RD STE 107
Practice Address - Street 2:
Practice Address - City:BERWYN HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20740-2355
Practice Address - Country:US
Practice Address - Phone:301-272-1558
Practice Address - Fax:301-272-1559
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR191756363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health