Provider Demographics
NPI:1437425568
Name:LAKE, ASHLEY ROSE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ROSE
Last Name:LAKE
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 RANDOLPH RD
Mailing Address - Street 2:SPORTS MEDICINE
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 RANDOLPH RD
Practice Address - Street 2:SPORTS MEDICINE
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1101
Practice Address - Country:US
Practice Address - Phone:336-716-8467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1758OtherNORTH CAROLINA BOARD OF ATHLETIC TRAINER EXAMINERS LICENSE NUMBER
2000004245OtherBOARD OF CERITIFICATION, INC. CERTIFICATION NUMBER