Provider Demographics
NPI:1700845534
Name:NYBERG-LAKE, NANCY (ARNP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:NYBERG-LAKE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 COLISEUM AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063-3206
Mailing Address - Country:US
Mailing Address - Phone:603-881-7141
Mailing Address - Fax:603-880-7221
Practice Address - Street 1:5 COLISEUM AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03063-3206
Practice Address - Country:US
Practice Address - Phone:603-881-7141
Practice Address - Fax:603-880-7221
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH051359-12207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH9598234OtherCIGNA HEALTHCARE
NH40Y008491NH01OtherANTHEM BC/BS
NH9598234OtherCIGNA HEALTHCARE
NHNP5044Medicare ID - Type Unspecified