Provider Demographics
NPI:1962634980
Name:LAKE, KATHRYN I (APRN)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:I
Last Name:LAKE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8342 US HIGHWAY 301 N
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-8653
Mailing Address - Country:US
Mailing Address - Phone:941-729-4400
Mailing Address - Fax:941-729-4424
Practice Address - Street 1:8342 US HIGHWAY 301 N
Practice Address - Street 2:
Practice Address - City:PARRISH
Practice Address - State:FL
Practice Address - Zip Code:34219-8653
Practice Address - Country:US
Practice Address - Phone:941-729-4400
Practice Address - Fax:941-729-4424
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9476735363L00000X, 363LF0000X
SC3968363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1883OtherSC MEDICAID
AA7053Medicare UPIN