Provider Demographics
NPI:1891449625
Name:LAKE, ALICIA LARAE (MSN, NP-C)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:LARAE
Last Name:LAKE
Suffix:
Gender:F
Credentials:MSN, NP-C
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:LARAE
Other - Last Name:LEWELLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-1239
Mailing Address - Country:US
Mailing Address - Phone:573-406-5888
Mailing Address - Fax:573-248-5264
Practice Address - Street 1:6500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6890
Practice Address - Country:US
Practice Address - Phone:573-629-3300
Practice Address - Fax:573-629-3314
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021023511363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily