Provider Demographics
NPI:1699198903
Name:LAKE MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:LAKE MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTIONEER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:561-992-0508
Mailing Address - Street 1:425 SE 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BELLE GLADE
Mailing Address - State:FL
Mailing Address - Zip Code:33430-3511
Mailing Address - Country:US
Mailing Address - Phone:561-992-0508
Mailing Address - Fax:561-992-0510
Practice Address - Street 1:425 SE 2ND ST
Practice Address - Street 2:
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-3511
Practice Address - Country:US
Practice Address - Phone:561-992-0508
Practice Address - Fax:561-992-0510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-23
Last Update Date:2014-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1951902363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHS692AMedicare PIN