Provider Demographics
NPI:1821532250
Name:LAKE, KIMBERLY JANE (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JANE
Last Name:LAKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 W 89TH ST
Mailing Address - Street 2:APARTMENT 11F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-1700
Mailing Address - Country:US
Mailing Address - Phone:917-533-8301
Mailing Address - Fax:
Practice Address - Street 1:250 W 89TH ST
Practice Address - Street 2:APARTMENT 11F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-1700
Practice Address - Country:US
Practice Address - Phone:917-533-8301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-03
Last Update Date:2016-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341106363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily