Provider Demographics
NPI:1619467537
Name:LAKE, LEAH (CERTIFIED NURSE ASSI)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:CERTIFIED NURSE ASSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 S KIRKMAN RD STE 310
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-7937
Mailing Address - Country:US
Mailing Address - Phone:321-332-4455
Mailing Address - Fax:
Practice Address - Street 1:5401 S KIRKMAN RD STE 310
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7937
Practice Address - Country:US
Practice Address - Phone:321-332-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty