Provider Demographics
NPI:1922461441
Name:LAKE, JENNIFER (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12201 BLUEGRASS PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2361
Mailing Address - Country:US
Mailing Address - Phone:502-568-7364
Mailing Address - Fax:502-568-7136
Practice Address - Street 1:3500 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-1732
Practice Address - Country:US
Practice Address - Phone:812-238-1555
Practice Address - Fax:812-238-2514
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71006171A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner