Provider Demographics
NPI:1487033007
Name:LAKE, SHARON G (APRN, NP-C)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:G
Last Name:LAKE
Suffix:
Gender:F
Credentials:APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 STONE PL
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9465
Mailing Address - Country:US
Mailing Address - Phone:304-539-1298
Mailing Address - Fax:304-766-3484
Practice Address - Street 1:4607 MACCORKLE AVE SW
Practice Address - Street 2:SUITE 300
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1364
Practice Address - Country:US
Practice Address - Phone:304-766-3688
Practice Address - Fax:304-766-3484
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV64723363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily