Provider Demographics
NPI:1477701647
Name:LAKE, KATRINA (LAC)
Entity Type:Individual
Prefix:MS
First Name:KATRINA
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E DEL MAR BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2544
Mailing Address - Country:US
Mailing Address - Phone:626-823-2809
Mailing Address - Fax:
Practice Address - Street 1:200 E DEL MAR BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2544
Practice Address - Country:US
Practice Address - Phone:626-823-2809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-30
Last Update Date:2008-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12222171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist