Provider Demographics
NPI:1629594882
Name:LAKE, AUTEUM (RN, NP-C)
Entity Type:Individual
Prefix:MISS
First Name:AUTEUM
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:RN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 BETTON ST STE 204
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-2636
Mailing Address - Country:US
Mailing Address - Phone:207-805-5900
Mailing Address - Fax:207-544-5107
Practice Address - Street 1:46 BETTON ST STE 204
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-2636
Practice Address - Country:US
Practice Address - Phone:207-805-5900
Practice Address - Fax:207-544-5107
Is Sole Proprietor?:No
Enumeration Date:2017-08-19
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP171055363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily