Provider Demographics
NPI:1669010518
Name:LAKE, FAMINDA T (FAMINDA)
Entity Type:Individual
Prefix:
First Name:FAMINDA
Middle Name:T
Last Name:LAKE
Suffix:
Gender:F
Credentials:FAMINDA
Other - Prefix:
Other - First Name:FAMINDA
Other - Middle Name:T
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:2343 MERSEYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-6568
Mailing Address - Country:US
Mailing Address - Phone:703-730-9597
Mailing Address - Fax:
Practice Address - Street 1:3300 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3307
Practice Address - Country:US
Practice Address - Phone:703-776-2632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-11
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001269149163W00000X
VA0024178894367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse