Provider Demographics
NPI:1942606009
Name:LAKE, KRISTEN M (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:LAKE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 COUNTY ROAD 44
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:13815-2209
Mailing Address - Country:US
Mailing Address - Phone:607-334-6273
Mailing Address - Fax:607-334-8770
Practice Address - Street 1:280 COUNTY ROAD 44
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-2209
Practice Address - Country:US
Practice Address - Phone:607-334-6273
Practice Address - Fax:607-334-8770
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY62038346225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist