Provider Demographics
NPI:1326384835
Name:LAKE, BRENDA KAY (RN)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
Last Name:LAKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3717 BAY RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:MI
Mailing Address - Zip Code:48133-9404
Mailing Address - Country:US
Mailing Address - Phone:419-297-4629
Mailing Address - Fax:734-723-4001
Practice Address - Street 1:3717 BAY RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:MI
Practice Address - Zip Code:48133-9404
Practice Address - Country:US
Practice Address - Phone:419-297-4629
Practice Address - Fax:734-723-4001
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-02
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH349091163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health