Provider Demographics
NPI:1972592699
Name:THOMAS, JACINTA LAKE (DNP, APRN-C)
Entity Type:Individual
Prefix:MRS
First Name:JACINTA
Middle Name:LAKE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:DNP, APRN-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1717 BENNETT DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-9039
Mailing Address - Country:US
Mailing Address - Phone:678-787-8647
Mailing Address - Fax:
Practice Address - Street 1:865 N HIGHLAND AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-4565
Practice Address - Country:US
Practice Address - Phone:404-733-6089
Practice Address - Fax:612-659-7101
Is Sole Proprietor?:No
Enumeration Date:2005-10-15
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN117444363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBJVXMedicare UPIN